Healthcare Provider Details

I. General information

NPI: 1295663854
Provider Name (Legal Business Name): EVANGELISTA DENTAL GROUP HILLCREST, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 5TH AVE STE 270
SAN DIEGO CA
92103-3137
US

IV. Provider business mailing address

3900 5TH AVE STE 270
SAN DIEGO CA
92103-3137
US

V. Phone/Fax

Practice location:
  • Phone: 619-810-1864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CASEY CASTLE
Title or Position: DIRECTOR OF PAYOR CONTRACTING
Credential:
Phone: 912-732-1504