MEDICARE: CLINICA DENTAL INTEGRAL

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	1223G0001X	General Practice Dentistry	MX15793	ZZ

General Provider Information

NPI Number	:	1457503922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICA DENTAL INTEGRAL

Provider Business Mailing Address
First Line	:	9379 IGNACIO COMONFORT
Second Line	:	SUITE 'B'
City	:	TIJUANA
State	:	BAJA CALIFORNIA
Zip	:	22210
Country	:	MX
Telephone Number	:	619-270-2243
Fax Number	:

Provider Business Practice Location Address
First Line	:	3045 S ARCHIBALD AVE
Second Line	:	SUITE H-289
City	:	ONTARIO
State	:	CA
Zip	:	91761-9001
Country	:	US
Telephone Number	:	909-758-8275
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JESSICA SERRANO
Credential	:
Telephone Number	:	619-270-2243

Provider Enumeration Date	:	10/16/2008
Last Update Date	:	10/16/2008

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