Healthcare Provider Details

I. General information

NPI: 1568972677
Provider Name (Legal Business Name): MARIO F. AGUERO M.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AV. FRANCISCO I. MADERO #1268-A
MEXICALI BAJA CALIFORNIA
21100
MX

IV. Provider business mailing address

109 HEFFERNAN AVE. PMB 81-064
CALEXICO CA
82231-2735
US

V. Phone/Fax

Practice location:
  • Phone: 760-886-8558
  • Fax: 858-430-3143
Mailing address:
  • Phone: 760-886-8558
  • Fax: 858-430-3143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9919272
License Number StateZZ

VIII. Authorized Official

Name: DR. MARIO F AGUERO
Title or Position: OWNER
Credential: D.D.S.
Phone: 760-886-8558