Healthcare Provider Details

I. General information

NPI: 1225318124
Provider Name (Legal Business Name): MARTIN F PUGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROSARIO CASTELLANOS # 10160 7B ZONA RIO
TIJUANA BAJA CALIFORINA
22300
MX

IV. Provider business mailing address

3221 NAYLOR RD
SAN YSIDRO CA
92173-4800
US

V. Phone/Fax

Practice location:
  • Phone: 619-861-4782
  • Fax:
Mailing address:
  • Phone: 619-207-2532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2312763 MEXICO
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: