Provider Demographics
NPI:1245467307
Name:DEMETRIO LANDEROS
Entity type:Organization
Organization Name:DEMETRIO LANDEROS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEMETRIO
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-734-2358
Mailing Address - Street 1:BLVD SANCHEZ TOBOADA #4002 C-9
Mailing Address - Street 2:
Mailing Address - City:TIJUANA
Mailing Address - State:BAJA CALIFORNIA
Mailing Address - Zip Code:22320
Mailing Address - Country:MX
Mailing Address - Phone:619-734-2358
Mailing Address - Fax:
Practice Address - Street 1:BLVD SANCHEZ TOBOADA #4002 C-9
Practice Address - Street 2:
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22320
Practice Address - Country:MX
Practice Address - Phone:619-734-2358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMEXUS DENTAL PPO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZMX7211911223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty