Provider Demographics
NPI:1083252464
Name:MACIAS, DENISSE PATRICIA (DDS)
Entity Type:Individual
Prefix:
First Name:DENISSE
Middle Name:PATRICIA
Last Name:MACIAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3975 CAMINO DE LA PLZ
Mailing Address - Street 2:STE 208 #1292
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173
Mailing Address - Country:US
Mailing Address - Phone:619-763-8258
Mailing Address - Fax:
Practice Address - Street 1:235 EAST ORANGE AVENUE
Practice Address - Street 2:APARTMENT E4
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911
Practice Address - Country:US
Practice Address - Phone:619-763-8258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1045741223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice