Healthcare Provider Details

I. General information

NPI: 1245681238
Provider Name (Legal Business Name): WENDOLYNE NASHELLY CORONA LEAL D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE ISLA TIBURON 3662 LAMAS DEL MATAMOROS
TIJUANA BAJA CALIFORNIA
22206
MX

IV. Provider business mailing address

4365 BONITA RD. #233
BONITA CA
91902-1421
US

V. Phone/Fax

Practice location:
  • Phone: 015526646657678
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6174536
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: