Healthcare Provider Details

I. General information

NPI: 1255037164
Provider Name (Legal Business Name): FEDERICO TAPIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLVD GUSTAVO DIAZ ORDAZ 13251 STE E11
TIJUANA BAJA CALIFORNIA
22106
MX

IV. Provider business mailing address

2013 DAIRY MART RD UNIT 3
SAN YSIDRO CA
92173-1848
US

V. Phone/Fax

Practice location:
  • Phone: 921-233-1679
  • Fax:
Mailing address:
  • Phone: 619-209-8924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: HECTOR MORALES
Title or Position: DENTAL BILLING DEPARTMENT
Credential:
Phone: 619-209-8924