Healthcare Provider Details

I. General information

NPI: 1720181290
Provider Name (Legal Business Name): SERGIO CUEVAS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 BEYER BLVD
SAN YSIDRO CA
92173-2007
US

IV. Provider business mailing address

4004 BEYER BLVD
SAN YSIDRO CA
92173-2007
US

V. Phone/Fax

Practice location:
  • Phone: 619-428-4463
  • Fax: 619-428-2625
Mailing address:
  • Phone: 619-428-4463
  • Fax: 619-428-2625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number41007
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: