Provider Demographics
NPI:1346655677
Name:ALFONSO, ANTONIO ANDREW JR (DMD)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:ANDREW
Last Name:ALFONSO
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 MOTT ST # 100-110
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-4237
Mailing Address - Country:US
Mailing Address - Phone:818-963-5690
Mailing Address - Fax:
Practice Address - Street 1:732 MOTT ST # 100-110
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4237
Practice Address - Country:US
Practice Address - Phone:818-963-5690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA635001223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA63500Medicaid