Healthcare Provider Details

I. General information

NPI: 1598026379
Provider Name (Legal Business Name): SONORTICA DENT ALL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 E SAN YSIDRO BLVD SUITE 1007
SAN YSIDRO CA
92173-3123
US

IV. Provider business mailing address

2043 E KRYSTAL STREET
SAN LUIS AZ
85349
US

V. Phone/Fax

Practice location:
  • Phone: 619-870-9456
  • Fax: 619-785-3404
Mailing address:
  • Phone: 619-870-9456
  • Fax: 619-785-3404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number2394636
License Number StateZZ

VIII. Authorized Official

Name: MR. CARLOS SANCHEZ
Title or Position: CEO
Credential:
Phone: 619-870-9456