Healthcare Provider Details

I. General information

NPI: 1730415324
Provider Name (Legal Business Name): FAMILY DENTAL CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2009
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HERMANOS ESCOBAR Y LINCOLN #201
CD JUAREZ CHIH
32310
MX

IV. Provider business mailing address

500 CANYON SPRINGS
EL PASO TX
79912
US

V. Phone/Fax

Practice location:
  • Phone: 011526566165689
  • Fax:
Mailing address:
  • Phone: 915-760-6234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5137963
License Number StateZZ

VIII. Authorized Official

Name: BERTHA NUNEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 915-760-6234