Provider Demographics
NPI:1881248417
Name:MG REYES DENTAL CORPORATION
Entity type:Organization
Organization Name:MG REYES DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-962-8160
Mailing Address - Street 1:14323 RAMONA BLVD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3242
Mailing Address - Country:US
Mailing Address - Phone:626-962-8160
Mailing Address - Fax:
Practice Address - Street 1:14323 RAMONA BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3242
Practice Address - Country:US
Practice Address - Phone:626-962-8160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN GABRIEL DENTAL PRACTICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-31
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619184223Medicaid
CA1619184223OtherDENTI-CAL
CA1619184223OtherMEDICAL