1417480369 NPI number — BORDER DENTAL CENTER DE NUEVO LAREDO SC

Table of content: (NPI 1417480369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417480369 NPI number — BORDER DENTAL CENTER DE NUEVO LAREDO SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BORDER DENTAL CENTER DE NUEVO LAREDO SC
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:
Provider Other Organization Name Type Code:
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:
1417480369
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1806 COMMERCE DR STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAREDO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78041-2884
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-645-9738
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SANTOS DEGOLLADO 2229
Provider Second Line Business Practice Location Address:
COLONIA GUERRERO
Provider Business Practice Location Address City Name:
NUEVO LAREDO
Provider Business Practice Location Address State Name:
TAMAULIPAS
Provider Business Practice Location Address Postal Code:
88240
Provider Business Practice Location Address Country Code:
MX
Provider Business Practice Location Address Telephone Number:
956-242-4144
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
VILLANUEVA
Authorized Official First Name:
GRACIELA
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
956-645-9738

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  1150654 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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