Provider Demographics
NPI:1174064737
Name:EZEQUIEL ANDRADE FUENTES
Entity type:Organization
Organization Name:EZEQUIEL ANDRADE FUENTES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EZEQUIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRADE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-730-0171
Mailing Address - Street 1:4275 EXECUTIVE SQ
Mailing Address - Street 2:STE 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:CALLE SEGUNDA #67
Practice Address - Street 2:EJIDO MARIANO MATAMOROS
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22204
Practice Address - Country:MX
Practice Address - Phone:619-730-0171
Practice Address - Fax:866-272-6924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ7593792122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty