=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376774349
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANTIOQUIA DENTAL CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2009
-----------------------------------------------------
Last Update Date | 08/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1727 SWEETWATER ROAD, SUITE Q
-----------------------------------------------------
City | NATIONAL CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-477-0045
-----------------------------------------------------
Fax | 619-477-5822
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1727 SWEETWATER ROAD, SUITE Q
-----------------------------------------------------
City | NATIONAL CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-477-0045
-----------------------------------------------------
Fax | 619-477-5822
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BENJAMIN SALVADOR ANTIOQUIA
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 619-477-0045
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 25111
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------