Healthcare Provider Details

I. General information

NPI: 1316685019
Provider Name (Legal Business Name): VANESSA FERNANDEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PASEO DE LOS HEROES 10289 INTERIOR 8002
TIJUANA BAJA CALIFORNIA
22010
MX

IV. Provider business mailing address

605 W SAN YSIDRO BLVD APT 188
SAN YSIDRO CA
92173-2364
US

V. Phone/Fax

Practice location:
  • Phone: 619-272-9021
  • Fax:
Mailing address:
  • Phone: 619-272-9021
  • Fax: 619-329-9663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. VANESSA FERNANDEZ
Title or Position: DENTIST
Credential: DDS
Phone: 619-272-9021