Healthcare Provider Details

I. General information

NPI: 1245509793
Provider Name (Legal Business Name): JORGE QUINTANILLA K.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2011
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2613 JM VELASCO ST SUITE 301
TIJUANA BC
22000
MX

IV. Provider business mailing address

PO BOX 210116
CHULA VISTA CA
91921-0116
US

V. Phone/Fax

Practice location:
  • Phone: 664-634-3331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number4929050
License Number StateZZ

VIII. Authorized Official

Name: MR. ALEJANDRO RAMOS
Title or Position: BILLING
Credential:
Phone: 619-992-6290