Healthcare Provider Details

I. General information

NPI: 1801288865
Provider Name (Legal Business Name): MARIA T QUINTANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2015
Last Update Date: 02/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1239 SILVER HAWK WAY
CHULA VISTA CA
91915-1669
US

IV. Provider business mailing address

CALLE 11 # 8911
TIJUANA MEXICO
22000
MX

V. Phone/Fax

Practice location:
  • Phone: 619-216-6217
  • Fax:
Mailing address:
  • Phone: 619-216-6217
  • Fax: 619-934-3624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2627570
License Number StateZZ

VIII. Authorized Official

Name: MR. ALEJANDRO A RAMOS
Title or Position: BILLER
Credential:
Phone: 619-216-6217