MEDICARE: SAMUEL G VELAZQUEZ DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	1255930	CA

General Provider Information

NPI Number	:	1053487785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL G VELAZQUEZ DDS

Provider Business Mailing Address
First Line	:	4492 CAMINO DE LA PLAZA
Second Line	:	#1009
City	:	SAN YSIDNO
State	:	CA
Zip	:	92173
Country	:	US
Telephone Number	:	619-250-7509
Fax Number	:	619-690-4585

Provider Business Practice Location Address
First Line	:	2216A CALLE TERCERA
Second Line	:	ZONA CENTRO
City	:	TIJUANA
State	:	BC
Zip	:	22000
Country	:	MX
Telephone Number	:	011526643880736
Fax Number	:	664-685-1991

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2006
Last Update Date	:	07/08/2007

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