Healthcare Provider Details

I. General information

NPI: 1659890531
Provider Name (Legal Business Name): GUILLERMO MARQUEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 09/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE 2DA #72 PLAZA CESAR
LOS ALGODONES BAJA CALIFORNIA
21970
MX

IV. Provider business mailing address

4275 EXECUTIVE SQUARE STE 200
LA JOLLA CA
92037-9123
US

V. Phone/Fax

Practice location:
  • Phone: 658-517-7437
  • Fax:
Mailing address:
  • Phone: 619-488-3200
  • Fax: 866-272-6924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3-3763390
License Number StateZZ

VIII. Authorized Official

Name: MR. GUILLERMO MARQUEZ
Title or Position: DENTIST
Credential: D.D.S.
Phone: 658-517-7437