Healthcare Provider Details

I. General information

NPI: 1346987435
Provider Name (Legal Business Name): CINTHIA G. HEREDIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2022
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GERMAN GEDOVIUS #104331, SUITE 302 ZONA RIO
TIJUANA BAJA CALIF
22010
MX

IV. Provider business mailing address

4364 BONITA ROAD #233
BONITA CA
91902-1421
US

V. Phone/Fax

Practice location:
  • Phone: 664-634-3177
  • Fax: 866-864-5572
Mailing address:
  • Phone: 619-421-6632
  • Fax: 866-864-5572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: MS. CINTHIA G HEREDIA
Title or Position: OWNER-SOLE PROPRIETOR
Credential: D.D.S.
Phone: 644-634-3177