Healthcare Provider Details

I. General information

NPI: 1639808199
Provider Name (Legal Business Name): VERAIL D RUACHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GLADIOLAS OBISPADO #11538
TIJUANA BC
22024
MX

IV. Provider business mailing address

4275 EXECUTIVE SQ STE 302
LA JOLLA CA
92037-9123
US

V. Phone/Fax

Practice location:
  • Phone: 619-488-3200
  • Fax: 619-908-1095
Mailing address:
  • Phone: 619-488-3200
  • Fax: 619-908-1095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. VERAIL DANIELA RUACHO
Title or Position: DENTIST
Credential: DDS
Phone: 619-488-3200