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Organization
NEW IMAGE DENTISTRY
Active
Organization
NEW IMAGE DENTISTRY
Active
Parent organization
MIRA MESA DENTAL CARE
Other names
Mira Mesa Dental Care
Organization subpart
Yes
Provider details
NPI number
Legal business name
MIRA MESA DENTAL CARE
Authorized official
DR. ROSSANA TABAL ALFONSO D.D.S. (OWNER)
(619) 470-2558
Entity
Organization
Contact information
Practice address
819 D AVENUE, SUITE 101, NATIONAL CITY, CA 91950-3465
(619) 470-2558
(619) 475-0799
Mailing address
819 D AVENUE, SUITE 101, NATIONAL CITY, CA 91950-3465
(619) 470-2558
(619) 475-0799
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
305R00000X
Preferred Provider Organization
49220
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1013114156
INDIVIDUAL NPI
CA
Enumeration date
12/13/2012
Last updated
06/17/2016
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