Healthcare Provider Details

I. General information

NPI: 1124357181
Provider Name (Legal Business Name): PRO DENT RIO BRAVO S. DE R.L DE C.V.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2009
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AV. ABRAHAM LINCOLN 201, LA PLAYA
CD. JUAREZ CHIH
32317
MX

IV. Provider business mailing address

279 SHADOW MTN DR # 229
EL PASO TX
79912-4707
US

V. Phone/Fax

Practice location:
  • Phone: 526566165689
  • Fax:
Mailing address:
  • Phone: 656-616-5689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateZZ

VIII. Authorized Official

Name: MS. FERNANDA FLORES
Title or Position: ADMINISTRATOR
Credential:
Phone: 526566165689