MEDICARE: REAL DENTAL CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	52460	CA

General Provider Information

NPI Number	:	1245681055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REAL DENTAL CORP

Provider Business Mailing Address
First Line	:	690 E ST
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-2113
Country	:	US
Telephone Number	:	619-425-2122
Fax Number	:	619-425-2125

Provider Business Practice Location Address
First Line	:	690 E ST
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-2113
Country	:	US
Telephone Number	:	619-425-2122
Fax Number	:	619-425-2125

Authorized Official
Title or Position	:	PRESIDENT/DENTIST
Name	:	DR. LUIS REAL
Credential	:	DDS
Telephone Number	:	619-425-2122

Provider Enumeration Date	:	06/23/2016
Last Update Date	:	06/23/2016

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Directions to “REAL DENTAL CORP ” Practice Location

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