Healthcare Provider Details

I. General information

NPI: 1053487785
Provider Name (Legal Business Name): SAMUEL G VELAZQUEZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SAMUEL VELAZQUEZ GUERRERD

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2216A CALLE TERCERA ZONA CENTRO
TIJUANA BC
22000
MX

IV. Provider business mailing address

4492 CAMINO DE LA PLAZA #1009
SAN YSIDNO CA
92173
US

V. Phone/Fax

Practice location:
  • Phone: 011526643880736
  • Fax: 664-685-1991
Mailing address:
  • Phone: 619-250-7509
  • Fax: 619-690-4585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1255930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: