1952820805 NPI number — JUAN MANUEL LIZARRAGA

Table of content: (NPI 1952820805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952820805 NPI number — JUAN MANUEL LIZARRAGA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUAN MANUEL LIZARRAGA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JUAN MANUEL LIZARRAGA D.D.S.
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952820805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4275 EXECUTIVE SQUARE
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-9123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-488-3200
Provider Business Mailing Address Fax Number:
866-272-6924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
INSURGENLES 910
Provider Second Line Business Practice Location Address:
FRACC. MARIA FERNANDA
Provider Business Practice Location Address City Name:
MAZATLAN
Provider Business Practice Location Address State Name:
SINALOA
Provider Business Practice Location Address Postal Code:
82147
Provider Business Practice Location Address Country Code:
MX
Provider Business Practice Location Address Telephone Number:
669-992-8700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
LIZZARAGA
Authorized Official First Name:
JUAN
Authorized Official Middle Name:
MANUEL
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
669-992-8700

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  5571815 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223E0200X , with the licence number: 7144794 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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