Healthcare Provider Details

I. General information

NPI: 1871270819
Provider Name (Legal Business Name): JOVITA MACIAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AV. IGNACIO ALLENDE 729
TIJUANA BAJA CALIFORNIA
22055
MX

IV. Provider business mailing address

482 W SAN YSIDRO BLVD APT 259
SAN YSIDRO CA
92173-2444
US

V. Phone/Fax

Practice location:
  • Phone: 664-477-9952
  • Fax:
Mailing address:
  • Phone: 619-272-9021
  • 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. JOVITA MACIAS
Title or Position: DENTIST
Credential: DDS
Phone: 619-270-9021