Healthcare Provider Details

I. General information

NPI: 1275932188
Provider Name (Legal Business Name): JOSE CARLOS CASTILLO D.D.S., M.A., M.M.SC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2014
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2918 FIFTH AVE STE 310
SAN DIEGO CA
92103-5910
US

IV. Provider business mailing address

2918 FIFTH AVE STE 310
SAN DIEGO CA
92103-5910
US

V. Phone/Fax

Practice location:
  • Phone: 619-295-2288
  • Fax:
Mailing address:
  • Phone: 619-295-2288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1856699
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDDS101338
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: