MEDICARE: KATY Y COVARRUBIAS

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

General Provider Information

NPI Number	:	1447038708
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KATY Y COVARRUBIAS

Provider Business Mailing Address
First Line	:	2455 OTAY CENTER DR # 117-514
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-7629
Country	:	US
Telephone Number	:	562-352-0417
Fax Number	:	562-366-0560

Provider Business Practice Location Address
First Line	:	AVE PASEO VILLA FONTANA 3711-5
Second Line	:
City	:	TIJUANA
State	:	BC
Zip	:	22205
Country	:	MX
Telephone Number	:	562-352-0417
Fax Number	:	562-366-0560

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. KATY Y COVARRUBIAS
Credential	:	DDS
Telephone Number	:	562-352-0417

Provider Enumeration Date	:	09/18/2023
Last Update Date	:	09/18/2023

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