Provider Demographics
NPI:1174078745
Name:OSCAR A BRACAMONTES DDS
Entity type:Organization
Organization Name:OSCAR A BRACAMONTES DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRACAMONTES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-946-1071
Mailing Address - Street 1:PO BOX 999
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91933-0999
Mailing Address - Country:US
Mailing Address - Phone:619-778-6765
Mailing Address - Fax:
Practice Address - Street 1:1144 13TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-3675
Practice Address - Country:US
Practice Address - Phone:619-946-1071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2763785122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2763785OtherLICENSE NUMBER