Healthcare Provider Details

I. General information

NPI: 1124683727
Provider Name (Legal Business Name): MARLENE I VERDUGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE HIDALGO #305
SAN LUIS RIO COLORADO SONORA
83449
MX

IV. Provider business mailing address

4275 EXECUTIVE SQ STE 200
LA JOLLA CA
92037-1476
US

V. Phone/Fax

Practice location:
  • Phone: 619-488-3200
  • Fax: 866-272-6924
Mailing address:
  • Phone:
  • 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. MARLENE ISABEL VERDUGO
Title or Position: DENTIST
Credential: DDS
Phone: 619-488-3200