Provider Demographics
NPI:1942938568
Name:DENISSE ELIZONDO DIAZ
Entity Type:Organization
Organization Name:DENISSE ELIZONDO DIAZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISSE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIZONDO DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-387-3104
Mailing Address - Street 1:2493 ROLL DR. 210-103
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154
Mailing Address - Country:US
Mailing Address - Phone:928-387-3104
Mailing Address - Fax:619-349-6409
Practice Address - Street 1:CALLE 8 Y MADERO #1205-5, ZONA CENTRO
Practice Address - Street 2:
Practice Address - City:TIJUANNA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:928-387-3104
Practice Address - Fax:619-349-6409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty