Healthcare Provider Details

I. General information

NPI: 1447080254
Provider Name (Legal Business Name): MICHELLE KARINA VEGA TERAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVENIDA B #300 SUITE 7
ALGODONES BAJA CALIFORNIA
21970
MX

IV. Provider business mailing address

PO BOX 1494
YUMA AZ
85366-2367
US

V. Phone/Fax

Practice location:
  • Phone: 658-596-2838
  • Fax:
Mailing address:
  • Phone: 928-287-1537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10402998
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: