Healthcare Provider Details

I. General information

NPI: 1730544990
Provider Name (Legal Business Name): GRELDA ITZELA VALENCIA CHAVEZ D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE ANTONIO CASO #2055-603, ZONA RIO TIJUANA
MEXICO BAJA CALIFORNIA
22010
MX

IV. Provider business mailing address

4364 BONITA RD #233
BONITA CA
91902-1421
US

V. Phone/Fax

Practice location:
  • Phone: 011526649729420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1859111
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: