Provider Demographics
NPI:1316482623
Name:JAVIER ALEJANDRO VIDES
Entity type:Organization
Organization Name:JAVIER ALEJANDRO VIDES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAVIER
Authorized Official - Middle Name:ALEJANDRO
Authorized Official - Last Name:VIDES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:800-743-3900
Mailing Address - Street 1:4275 EXECUTIVE SQ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:800-743-3900
Mailing Address - Fax:866-272-6924
Practice Address - Street 1:GONZALEZ DE COSSIO 1
Practice Address - Street 2:SUITE 103
Practice Address - City:MEXICO CITY
Practice Address - State:MEXICO
Practice Address - Zip Code:03100
Practice Address - Country:MX
Practice Address - Phone:551-107-6204
Practice Address - Fax:866-272-6924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ2486675122300000X
ZZ34445761223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty