MEDICARE: SERGIO HUGO PALACIOS

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	5748858	ZZ

General Provider Information

NPI Number	:	1750891800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERGIO HUGO PALACIOS

Provider Business Mailing Address
First Line	:	4275 EXECUTIVE SQUARE
Second Line	:	SUITE 200
City	:	LA JOLLA
State	:	CA
Zip	:	92037-9123
Country	:	US
Telephone Number	:	619-488-3200
Fax Number	:	866-272-6924

Provider Business Practice Location Address
First Line	:	LAS PALMAS 4571-3
Second Line	:
City	:	TIJUANA
State	:	BAJA CALIFORNIA
Zip	:	22160
Country	:	MX
Telephone Number	:	664-449-4649
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	MR. SERGIO HUGO PALACIOS
Credential	:	D.D.S.
Telephone Number	:	619-488-3200

Provider Enumeration Date	:	10/03/2017
Last Update Date	:	10/03/2017

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