Provider Demographics
NPI:1093227373
Name:JUAN MANUEL CAMACHO
Entity type:Organization
Organization Name:JUAN MANUEL CAMACHO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:CAMACHO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-488-3200
Mailing Address - Street 1:4275 EXECUTIVE SQUARE
Mailing Address - Street 2:STE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:619-488-3200
Mailing Address - Fax:866-272-6924
Practice Address - Street 1:MARIANO MA LEE #174
Practice Address - Street 2:
Practice Address - City:LOS ALGODONEL
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:21970
Practice Address - Country:MX
Practice Address - Phone:686-517-7713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ653342122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty