MEDICARE: VERAIL D RUACHO

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

General Provider Information

NPI Number	:	1639808199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VERAIL D RUACHO

Provider Business Mailing Address
First Line	:	4275 EXECUTIVE SQ STE 302
Second Line	:
City	:	LA JOLLA
State	:	CA
Zip	:	92037-9123
Country	:	US
Telephone Number	:	619-488-3200
Fax Number	:	619-908-1095

Provider Business Practice Location Address
First Line	:	GLADIOLAS OBISPADO #11538
Second Line	:
City	:	TIJUANA
State	:	BC
Zip	:	22024
Country	:	MX
Telephone Number	:	619-488-3200
Fax Number	:	619-908-1095

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. VERAIL DANIELA RUACHO
Credential	:	DDS
Telephone Number	:	619-488-3200

Provider Enumeration Date	:	06/08/2022
Last Update Date	:	06/08/2022

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