Healthcare Provider Details

I. General information

NPI: 1760170708
Provider Name (Legal Business Name): KARLA MORENO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLVD GRAL RODOLFO SANCHEZ TABOADA 16004-6
TIJUANA BAJA CALIFORNIA
22010
MX

IV. Provider business mailing address

4630 BORDER VILLAGE RD # N1698
SAN YSIDRO CA
92173-3121
US

V. Phone/Fax

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

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. KARLA MORENO
Title or Position: DENTIST
Credential: DDS
Phone: 619-272-9021