MEDICARE: DR. MYRNA ESCOTO LAZAGA DMD

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	43356	CA

General Provider Information

NPI Number	:	1518179779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MYRNA ESCOTO LAZAGA DMD

Provider Business Mailing Address
First Line	:	914 E 8TH ST
Second Line	:	STE.208
City	:	NATIONAL CITY
State	:	CA
Zip	:	91950-2567
Country	:	US
Telephone Number	:	619-477-0570
Fax Number	:	619-477-1813

Provider Business Practice Location Address
First Line	:	914 E 8TH ST
Second Line	:	STE.208
City	:	NATIONAL CITY
State	:	CA
Zip	:	91950-2567
Country	:	US
Telephone Number	:	619-477-0570
Fax Number	:	619-477-1813

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

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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