=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225655335
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAIRO CASTRO, D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2020
-----------------------------------------------------
Last Update Date | 07/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1723 DURFEE AVE
-----------------------------------------------------
City | SOUTH EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91733-4557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-401-3000
-----------------------------------------------------
Fax | 626-416-5433
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1723 DURFEE AVE
-----------------------------------------------------
City | SOUTH EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91733-4557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-401-3000
-----------------------------------------------------
Fax | 626-416-5433
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAIRO CASTRO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 323-401-3000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------