Provider Demographics
NPI:1073782710
Name:MARIA BORRERO DENTAL CORP
Entity Type:Organization
Organization Name:MARIA BORRERO DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:CAMILA
Authorized Official - Last Name:BORRERO FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-498-8167
Mailing Address - Street 1:569 W LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3081
Mailing Address - Country:US
Mailing Address - Phone:626-966-3063
Mailing Address - Fax:
Practice Address - Street 1:569 W LOWELL AVE
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3081
Practice Address - Country:US
Practice Address - Phone:626-966-3063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA510461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty