Healthcare Provider Details

I. General information

NPI: 1073024303
Provider Name (Legal Business Name): LAURA IVONNE RENDON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 10/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 CALLE 4
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: 658-517-7711
  • Fax:
Mailing address:
  • Phone: 619-488-3200
  • Fax: 866-272-6924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number7594023
License Number StateZZ
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5229353
License Number StateZZ

VIII. Authorized Official

Name: MRS. LAURA IVONNE RENDON
Title or Position: DENTIST
Credential: D.D.S.
Phone: 619-488-3200