Provider Demographics
NPI:1851365043
Name:VIDALES, BEATRIZ (DDS)
Entity type:Individual
Prefix:
First Name:BEATRIZ
Middle Name:
Last Name:VIDALES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 GRAND AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-1241
Mailing Address - Country:US
Mailing Address - Phone:760-744-0004
Mailing Address - Fax:760-744-0001
Practice Address - Street 1:744 GRAND AVE STE 203
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-1241
Practice Address - Country:US
Practice Address - Phone:760-744-0004
Practice Address - Fax:760-744-0001
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA452121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4521201OtherMEDI-CAL IDENTIFICATION #
CA980769OtherUNITED CONCORDIA
CAB4521201OtherHEALTY FAMMILIES ID