MEDICARE: DEMETRIO LANDEROS

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	1223P0106X	Oral and Maxillofacial Pathology Dentistry	MX721191	ZZ

General Provider Information

NPI Number	:	1245467307
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEMETRIO LANDEROS

Provider Business Mailing Address
First Line	:	BLVD SANCHEZ TOBOADA #4002 C-9
Second Line	:
City	:	TIJUANA
State	:	BAJA CALIFORNIA
Zip	:	22320
Country	:	MX
Telephone Number	:	619-734-2358
Fax Number	:

Provider Business Practice Location Address
First Line	:	BLVD SANCHEZ TOBOADA #4002 C-9
Second Line	:
City	:	TIJUANA
State	:	BAJA CALIFORNIA
Zip	:	22320
Country	:	MX
Telephone Number	:	619-734-2358
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DEMETRIO LANDEROS
Credential	:
Telephone Number	:	619-734-2358

Provider Enumeration Date	:	06/16/2009
Last Update Date	:	06/16/2009

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Directions to “DEMETRIO LANDEROS ” Practice Location

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