Provider Demographics
NPI:1558862599
Name:DAVID GONGORA
Entity type:Organization
Organization Name:DAVID GONGORA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GONGORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-488-3200
Mailing Address - Street 1:BLVD EL MIRADOR #548 - 1
Mailing Address - Street 2:
Mailing Address - City:TIJUANA
Mailing Address - State:BAJA CALIFORNIA
Mailing Address - Zip Code:22520
Mailing Address - Country:MX
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BLVD EL MIRADOR #548 - 1
Practice Address - Street 2:
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22520
Practice Address - Country:MX
Practice Address - Phone:619-488-3200
Practice Address - Fax:866-272-6924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
75938371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty