Provider Demographics
NPI:1215326392
Name:ELIZABETH HERAS QUINTERO
Entity type:Organization
Organization Name:ELIZABETH HERAS QUINTERO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:HERAS
Authorized Official - Last Name:QUINTERO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-400-3360
Mailing Address - Street 1:710 E SAN YSIDRO BLVD
Mailing Address - Street 2:STE. 231
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-3123
Mailing Address - Country:US
Mailing Address - Phone:619-400-3360
Mailing Address - Fax:
Practice Address - Street 1:FRANCISCO JAVIER MINA #1415,
Practice Address - Street 2:STE. 103, ZONA RIO
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22010
Practice Address - Country:MX
Practice Address - Phone:619-400-3360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ41235561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty