Healthcare Provider Details

I. General information

NPI: 1689115685
Provider Name (Legal Business Name): ENRIQUE MORENO ESCOBAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 ALVARO OBREGON COLONIA 5 DE FEBRERO
NOGALES SONORA
84030
MX

IV. Provider business mailing address

4275 EXECUTIVE SQ SUITE 200
LA JOLLA CA
92037-9123
US

V. Phone/Fax

Practice location:
  • Phone: 520-313-5999
  • Fax: 866-272-6924
Mailing address:
  • Phone: 619-488-3200
  • Fax: 866-272-6924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6274742
License Number StateZZ

VIII. Authorized Official

Name: DR. ENRIQUE MORENO ESCOBAR
Title or Position: DENTIST
Credential: DDS
Phone: 520-313-5999