Provider Demographics
NPI:1073024303
Name:LAURA IVONNE RENDON
Entity Type:Organization
Organization Name:LAURA IVONNE RENDON
Other - Org Name:LAURA IVONNE RENDON D.D.S.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:IVONNE
Authorized Official - Last Name:RENDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-488-3200
Mailing Address - Street 1:4275 EXECUTIVE SQUARE
Mailing Address - Street 2:STE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:619-488-3200
Mailing Address - Fax:866-272-6924
Practice Address - Street 1:149 CALLE 4
Practice Address - Street 2:
Practice Address - City:LOS ALGODONES
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:21970
Practice Address - Country:MX
Practice Address - Phone:658-517-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ5229353122300000X
ZZ75940231223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty