Healthcare Provider Details

I. General information

NPI: 1871883389
Provider Name (Legal Business Name): ELISA MEZA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BENITO JUAREZ (CALLE 2DA) 1844-1 ZONA CENTRO
TIJUANA BAJA CALIFORNIA
22000
MX

IV. Provider business mailing address

416 W SAN YSIDRO BLVD STE 1416
SAN DIEGO CA
92173-2443
US

V. Phone/Fax

Practice location:
  • Phone: 664-685-8632
  • Fax: 664-685-8632
Mailing address:
  • Phone: 619-488-4010
  • Fax: 619-559-0744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4964081
License Number StateZZ
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4316145
License Number StateZZ
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14724
License Number StateZZ
# 4
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number16057
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: