Provider Demographics
NPI:1164880373
Name:QUINTANILLA ENCISO, SERGIO IVAN (DDS)
Entity Type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:IVAN
Last Name:QUINTANILLA ENCISO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4364 BONITA RD
Mailing Address - Street 2:#233
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CALLE JOSE MA. VELAZCO 2613-203
Practice Address - Street 2:ZONA RIO
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22320
Practice Address - Country:MX
Practice Address - Phone:01152664-634-7018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ302410122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist