MEDICARE: EDINBURG DENTAL, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	22644	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104364165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDINBURG DENTAL, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 102
Second Line	:
City	:	SAN JUAN
State	:	TX
Zip	:	78589-0102
Country	:	US
Telephone Number	:	956-537-6764
Fax Number	:

Provider Business Practice Location Address
First Line	:	423 W FM 495
Second Line	:
City	:	SAN JUAN
State	:	TX
Zip	:	78589-3717
Country	:	US
Telephone Number	:	956-537-6764
Fax Number	:

Authorized Official
Title or Position	:	PEDIATRIC DENTIST/OWNER
Name	:	DR. SERGIO IVAN GUZMAN
Credential	:	DDS
Telephone Number	:	956-537-6764

Provider Enumeration Date	:	02/09/2017
Last Update Date	:	02/09/2017

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