Provider Demographics
NPI:1386261527
Name:HERRERA SORIA, SERGIO
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:HERRERA SORIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2475 PASEO DE LAS AMERICAS # 1848
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-7255
Mailing Address - Country:US
Mailing Address - Phone:619-207-4089
Mailing Address - Fax:
Practice Address - Street 1:BLVD AGUA CALIENTE #4558
Practice Address - Street 2:PISOC C2, CENTRO MEDICO2, CONSULTORIO #10 (CM2-10)
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22014
Practice Address - Country:MX
Practice Address - Phone:664-971-0125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-04
Last Update Date:2020-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ8556315122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist