Healthcare Provider Details

I. General information

NPI: 1992627889
Provider Name (Legal Business Name): MARTHA SOFIA ZALDIVAR RUENES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19071 BEAR VALLEY RD
APPLE VALLEY CA
92308-2718
US

IV. Provider business mailing address

HACIENDA LA NEGRETA 225A BALCONES DEL CAMPESTRE
LEON GUANAJUATO
37138
MX

V. Phone/Fax

Practice location:
  • Phone: 909-256-9824
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113670
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: