Healthcare Provider Details

I. General information

NPI: 1952820805
Provider Name (Legal Business Name): JUAN MANUEL LIZARRAGA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 09/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

INSURGENLES 910 FRACC. MARIA FERNANDA
MAZATLAN SINALOA
82147
MX

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 669-992-8700
  • Fax:
Mailing address:
  • Phone: 619-488-3200
  • Fax: 866-272-6924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7144794
License Number StateZZ
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5571815
License Number StateZZ

VIII. Authorized Official

Name: MR. JUAN MANUEL LIZZARAGA
Title or Position: DENTIST
Credential: D.D.S.
Phone: 669-992-8700