MEDICARE: CLINICA DENTAL AZTECA DE TIJUANA

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	4685221	ZZ
2	122300000X	Dentist	805918	ZZ

General Provider Information

NPI Number	:	1417284795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICA DENTAL AZTECA DE TIJUANA

Provider Business Mailing Address
First Line	:	378 VANCE ST APT 7
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-4573
Country	:	US
Telephone Number	:	619-446-6657
Fax Number	:

Provider Business Practice Location Address
First Line	:	CALLE 6TH 1842, ZONA CENTRO
Second Line	:
City	:	TIJUANA
State	:	BAJA CALIFORNIA
Zip	:	22000
Country	:	MX
Telephone Number	:	619-446-6657
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. AURORA SANCHEZ
Credential	:
Telephone Number	:	619-804-6521

Provider Enumeration Date	:	11/07/2009
Last Update Date	:	06/29/2010

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