Provider Demographics
NPI:1689115685
Name:ENRIQUE MORENO ESCOBAR
Entity Type:Organization
Organization Name:ENRIQUE MORENO ESCOBAR
Other - Org Name:ENRIQUE MORENO DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO ESCOBAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-313-5999
Mailing Address - Street 1:4275 EXECUTIVE SQ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:619-488-3200
Mailing Address - Fax:866-272-6924
Practice Address - Street 1:72 ALVARO OBREGON
Practice Address - Street 2:COLONIA 5 DE FEBRERO
Practice Address - City:NOGALES
Practice Address - State:SONORA
Practice Address - Zip Code:84030
Practice Address - Country:MX
Practice Address - Phone:520-313-5999
Practice Address - Fax:866-272-6924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
ZZ62747421223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty