Provider Demographics
NPI:1215074836
Name:AGUILERA, KEITH BRIAN (DDS)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:BRIAN
Last Name:AGUILERA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 GATEWAY CENTER WAY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4500
Mailing Address - Country:US
Mailing Address - Phone:619-263-6648
Mailing Address - Fax:619-263-9353
Practice Address - Street 1:995 GATEWAY CENTER WAY
Practice Address - Street 2:SUITE 301
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4500
Practice Address - Country:US
Practice Address - Phone:619-263-6648
Practice Address - Fax:619-263-9353
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25113122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist