Healthcare Provider Details

I. General information

NPI: 1487168480
Provider Name (Legal Business Name): BRENDA CONTRERAS OLVERA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE TECOLOTE 19837 AMP GUAYCURA
TIJUANA B MEXICO
22214
MX

IV. Provider business mailing address

4275 EXECUTIVE SQUARE STE 200
LA JOLLA CA
92037-9123
US

V. Phone/Fax

Practice location:
  • Phone: 664-681-8118
  • Fax:
Mailing address:
  • Phone: 619-488-3200
  • Fax: 866-272-6924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8155035
License Number StateZZ

VIII. Authorized Official

Name: MRS. BRENDA CONTRERAS OLVERA
Title or Position: DENTIST
Credential: DDS
Phone: 664-681-8118