MEDICARE: PABLO ENRIQUE LICIAGA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	49365	CA

General Provider Information

NPI Number	:	1033126677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PABLO ENRIQUE LICIAGA DDS

Provider Business Mailing Address
First Line	:	2115 BACON ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107
Country	:	US
Telephone Number	:	619-224-2986
Fax Number	:	619-224-2982

Provider Business Practice Location Address
First Line	:	2115 BACON ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107
Country	:	US
Telephone Number	:	619-224-2986
Fax Number	:	619-224-2982

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	07/08/2007

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