Provider Demographics
NPI:1548614720
Name:INZUNZA LAVEAGA, MYRIAM (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MYRIAM
Middle Name:
Last Name:INZUNZA LAVEAGA
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 1:4364 BONITA RD # 233
Mailing Address - Street 2:
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:AVE LAS PALMAS 4531
Practice Address - Street 2:FRACC. LAS PALMAS
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22106
Practice Address - Country:MX
Practice Address - Phone:01152664-681-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ2388498122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist