| Blue Crystal Dental | |
|
432 N Riverside Ave Rialto CA 92376-5012 | |
| (909) 874-2121 | |
| Not Available |
| Full Name | Blue Crystal Dental |
|---|---|
| Speciality | Dentist |
| Location | 432 N Riverside Ave, Rialto, California |
| Authorized Official Name and Position | Pedro M Sandoval (PRESIDENT) |
| Authorized Official Contact | 9098739707 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Blue Crystal Dental 432 N Riverside Ave Rialto CA 92376-5012 Ph: (909) 874-2121 | Blue Crystal Dental 432 N Riverside Ave Rialto CA 92376-5012 Ph: (909) 874-2121 |
| NPI Number | 1043590060 |
|---|---|
| Provider Enumeration Date | 08/22/2011 |
| Last Update Date | 04/09/2019 |
| Medicare PECOS PAC ID | 7911240908 |
|---|---|
| Medicare Enrollment ID | O20190514002392 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1043590060 | NPI | - | NPPES |
| G8924701 | Other | CA | MEDI-CAL |
| 1194941245 | Other | CA | EIN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 49402 (California) | Primary |
| Provider Name | Pedro Miguel Sandoval |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1194941245 PECOS PAC ID: 8820331812 Enrollment ID: I20190514002451 |
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