Healthcare Provider Details

I. General information

NPI: 1093221830
Provider Name (Legal Business Name): MARIA CLARISA LUKEN RASCON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AV. A. NUM 235
ALGODONES B.C.
21970
MX

IV. Provider business mailing address

4275 EXECUTIVE SQUARE STE 200
LA JOLLA CA
92037-9123
US

V. Phone/Fax

Practice location:
  • Phone: 669-992-8700
  • Fax:
Mailing address:
  • Phone: 619-488-3200
  • Fax: 866-272-6924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number7953115
License Number StateZZ

VIII. Authorized Official

Name: MRS. MARIA CLARISA LUKEN RASCON
Title or Position: DENTIST
Credential: D.D.S.
Phone: 619-488-3200