Provider Demographics
NPI:1568256329
Name:CENTRO MEDICO AND DENTAL INC
Entity type:Organization
Organization Name:CENTRO MEDICO AND DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-949-5002
Mailing Address - Street 1:514 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3723
Mailing Address - Country:US
Mailing Address - Phone:213-749-3934
Mailing Address - Fax:213-749-0994
Practice Address - Street 1:514 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3723
Practice Address - Country:US
Practice Address - Phone:213-749-3934
Practice Address - Fax:213-749-0994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental