Healthcare Provider Details

I. General information

NPI: 1679307235
Provider Name (Legal Business Name): MOISES IRAZOQUI M
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 08/27/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DR ATL 2031-103 EDIFICIO MAPFRE ZONA RIO
TIJUANA BAJA CALIFORNIA
22010
MX

IV. Provider business mailing address

210 H ST APT L12
CHULA VISTA CA
91910
US

V. Phone/Fax

Practice location:
  • Phone: 664-210-7218
  • Fax: 619-354-2449
Mailing address:
  • Phone: 619-349-6409
  • Fax: 619-354-2449

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. MOISES IRAZOQUI M
Title or Position: OWNER
Credential: DDS
Phone: 664-210-7218