Healthcare Provider Details

I. General information

NPI: 1750644563
Provider Name (Legal Business Name): ELIZABETH HERAS QUINTERO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE FRANCISCO JAVIER MINA #1415 EDIF. MEXCHINO PRIMER PISO INT. 103 ZONA RIO
TIJUANA B.C
22320
MX

IV. Provider business mailing address

PMB #231 710 E SAN YSIDRO BLVD
SAN YSIDRO CA
92173-3193
US

V. Phone/Fax

Practice location:
  • Phone: 619-400-3360
  • Fax:
Mailing address:
  • Phone: 619-948-6103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4123556
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: