Healthcare Provider Details

I. General information

NPI: 1245695485
Provider Name (Legal Business Name): JORGE LUIS NAVIDAD MONJARDIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLVD. SANCHEZ TABOADA 9250-9 ZONA RIO
TIJUANA CA
22900
MX

IV. Provider business mailing address

4364 BONITA RD # 233
BONITA CA
91902-1421
US

V. Phone/Fax

Practice location:
  • Phone: 011526646847040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2804299
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: