Provider Demographics
NPI:1053487785
Name:VELAZQUEZ, SAMUEL G (DDS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:G
Last Name:VELAZQUEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:VELAZQUEZ
Other - Last Name:GUERRERD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4492 CAMINO DE LA PLAZA
Mailing Address - Street 2:#1009
Mailing Address - City:SAN YSIDNO
Mailing Address - State:CA
Mailing Address - Zip Code:92173
Mailing Address - Country:US
Mailing Address - Phone:619-250-7509
Mailing Address - Fax:619-690-4585
Practice Address - Street 1:2216A CALLE TERCERA
Practice Address - Street 2:ZONA CENTRO
Practice Address - City:TIJUANA
Practice Address - State:BC
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:01152664-388-0736
Practice Address - Fax:664-685-1991
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1255930122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist