Healthcare Provider Details

I. General information

NPI: 1558187971
Provider Name (Legal Business Name): ESCONDIDO MODERN DENTISTRY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 W MISSION AVE
ESCONDIDO CA
92025-1611
US

IV. Provider business mailing address

PO BOX 920050
DALLAS TX
75392-0050
US

V. Phone/Fax

Practice location:
  • Phone: 442-273-2325
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: YIGE ZHAO
Title or Position: OWNER
Credential:
Phone: 714-845-8890