Healthcare Provider Details

I. General information

NPI: 1770287146
Provider Name (Legal Business Name): SANDRA LEON VAZQUEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVENIDA NEGRETE # 1577 CALLE 7 Y 8 ZONA CENTRO
TIJUANA BAJA CALIFORIA
92173
MX

IV. Provider business mailing address

641 E SAN YSIDRO BLVD. #B3-1952
SAN YSIDRO CA
92173
US

V. Phone/Fax

Practice location:
  • Phone: 664-660-7902
  • Fax: 619-354-2449
Mailing address:
  • Phone: 664-660-7902
  • Fax: 619-354-2449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SANDRA LEON VAZQUEZ
Title or Position: OWNER
Credential:
Phone: 619-349-6409