Healthcare Provider Details

I. General information

NPI: 1730647769
Provider Name (Legal Business Name): DENTAL LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE MIGUEL IDALFO Y COSTILLA NO. 65 COL. FUNDO LEGAL
NOGALES SONORA
84030
MX

IV. Provider business mailing address

PO BOX 243
NOGALES AZ
85628-0243
US

V. Phone/Fax

Practice location:
  • Phone: 520-313-1494
  • Fax:
Mailing address:
  • Phone: 520-313-1494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERTO CARLOS JAUREGUI LEWIS
Title or Position: ODONTOLOGY & DENTISTRY
Credential:
Phone: 520-313-1494