MEDICARE: MARCELA PERALTA 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	1223G0001X	General Practice Dentistry	110469	CA

General Provider Information

NPI Number	:	1336970516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCELA PERALTA DDS

Provider Business Mailing Address
First Line	:	6977 PARKSIDE AVE APT C
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92139-3856
Country	:	US
Telephone Number	:	619-755-2105
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 FIFTH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-5053
Country	:	US
Telephone Number	:	619-298-2893
Fax Number	:

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

Provider Enumeration Date	:	08/09/2024
Last Update Date	:	08/09/2024

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