Healthcare Provider Details

I. General information

NPI: 1134626005
Provider Name (Legal Business Name): JESUS A CEBALLOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE B #150 SUITE H
LOS ALGODONES BAJA CALIFORNIA
21970
MX

IV. Provider business mailing address

AVE B #150 SUITE H
LOS ALGODONES BAJA CALIFORNIA
21970
MX

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5466814
License Number StateZZ

VIII. Authorized Official

Name: DR. JESUS A CEBALLOS
Title or Position: DENTIST
Credential: DDS
Phone: 619-488-3200