Healthcare Provider Details

I. General information

NPI: 1841706660
Provider Name (Legal Business Name): LIDIA RIVERA ORDAZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLVD. LAZARO CARDENAS Y PASEO GRANDES LAGOS #301
MEXICAI BAJA CALIFORNIA
21330
MX

IV. Provider business mailing address

233 PAULIN AVE. #7649
CALEXICO CA
92231
US

V. Phone/Fax

Practice location:
  • Phone: 760-234-3835
  • Fax: 858-430-3143
Mailing address:
  • Phone: 760-234-3835
  • Fax: 858-430-3143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6130002
License Number StateZZ

VIII. Authorized Official

Name: DR. LIDIA RIVERA ORDAZ
Title or Position: OWNER
Credential: D.D.S.
Phone: 760-234-3835