Healthcare Provider Details

I. General information

NPI: 1952647208
Provider Name (Legal Business Name): NEW IMAGE DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2012
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 D AVENUE, SUITE 101
NATIONAL CITY CA
91950-3465
US

IV. Provider business mailing address

819 D AVENUE, SUITE 101
NATIONAL CITY CA
91950-3465
US

V. Phone/Fax

Practice location:
  • Phone: 619-470-2558
  • Fax: 619-475-0799
Mailing address:
  • Phone: 619-470-2558
  • Fax: 619-475-0799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number49220
License Number StateCA

VIII. Authorized Official

Name: DR. ROSSANA TABAL ALFONSO
Title or Position: OWNER
Credential: D.D.S.
Phone: 619-470-2558