Healthcare Provider Details

I. General information

NPI: 1447622907
Provider Name (Legal Business Name): EDGAR PEREZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

C. 2DA Y CAALLEJON INTERNACIONAL #200-4
SAN LUIS RIO COLORADO SONORA
83450
MX

IV. Provider business mailing address

PO BOX 8490 PMB 206
SAN LUIS AZ
85349-6829
US

V. Phone/Fax

Practice location:
  • Phone: 928-239-5910
  • Fax: 858-430-3143
Mailing address:
  • Phone: 928-239-5910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5496935
License Number StateZZ

VIII. Authorized Official

Name: DR. EDGAR ZAID PEREZ
Title or Position: OWNER
Credential: DDS
Phone: 928-239-5910