MEDICARE: ELIZABETH HERAS QUINTERO 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	122300000X	Dentist	4123556	ZZ

General Provider Information

NPI Number	:	1750644563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH HERAS QUINTERO DDS

Provider Business Mailing Address
First Line	:	PMB #231
Second Line	:	710 E SAN YSIDRO BLVD
City	:	SAN YSIDRO
State	:	CA
Zip	:	92173-3193
Country	:	US
Telephone Number	:	619-948-6103
Fax Number	:

Provider Business Practice Location Address
First Line	:	CALLE FRANCISCO JAVIER MINA #1415
Second Line	:	EDIF. MEXCHINO PRIMER PISO INT. 103 ZONA RIO
City	:	TIJUANA
State	:	B.C
Zip	:	22320
Country	:	MX
Telephone Number	:	619-400-3360
Fax Number	:

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

Provider Enumeration Date	:	06/18/2012
Last Update Date	:	06/18/2012

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