=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245681238
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WENDOLYNE NASHELLY CORONA LEAL D.D.S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2016
-----------------------------------------------------
Last Update Date | 06/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | AVE ISLA TIBURON 3662 LAMAS DEL MATAMOROS
-----------------------------------------------------
City | TIJUANA
-----------------------------------------------------
State | BAJA CALIFORNIA
-----------------------------------------------------
Zip | 22206
-----------------------------------------------------
Country | MX
-----------------------------------------------------
Telephone | 015526646657678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4365 BONITA RD. #233
-----------------------------------------------------
City | BONITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91902-1421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6174536
-----------------------------------------------------
License Number State | ZZ
-----------------------------------------------------