Healthcare Provider Details

I. General information

NPI: 1518576461
Provider Name (Legal Business Name): ANDRES FELIPE CASALLAS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 08/28/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 PALM AVE
IMPERIAL BEACH CA
91932-1503
US

IV. Provider business mailing address

9229 REGENTS RD UNIT 216
LA JOLLA CA
92037-9272
US

V. Phone/Fax

Practice location:
  • Phone: 619-429-3733
  • Fax:
Mailing address:
  • Phone: 510-754-9754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number105112
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: