1881745495 NPI number — MR. JUAN AVILA DDS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881745495 NPI number — MR. JUAN AVILA DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AVILA
Provider First Name:
JUAN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AVILA
Provider Other First Name:
JOHN
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.D.S.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1881745495
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8409 W CLEBURNE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-292-5927
Provider Business Mailing Address Fax Number:
817-292-9595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8409 W. CLEBURNE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-292-5927
Provider Business Practice Location Address Fax Number:
817-292-9595
Provider Enumeration Date:
01/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  15551 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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