Provider Demographics
NPI:1275636870
Name:MEZA-CRESPO, MAXIMO DANIEL (DDS)
Entity Type:Individual
Prefix:
First Name:MAXIMO
Middle Name:DANIEL
Last Name:MEZA-CRESPO
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 1:1275 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3476
Mailing Address - Country:US
Mailing Address - Phone:619-662-4100
Mailing Address - Fax:
Practice Address - Street 1:3177 OCEAN VIEW BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-1432
Practice Address - Country:US
Practice Address - Phone:619-662-4100
Practice Address - Fax:619-232-5922
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42572122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
522114Medicare UPIN