Healthcare Provider Details

I. General information

NPI: 1700113537
Provider Name (Legal Business Name): DENTAL LASER & IMPLANT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2009
Last Update Date: 11/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTRO EJECTIVO PLAZA JUAREZ LINCOLN #205
CD. JUAREZ CHIH
36310
MX

IV. Provider business mailing address

7101 N. MESA #538
EL PASO TX
79912
US

V. Phone/Fax

Practice location:
  • Phone: 011526566116561
  • Fax:
Mailing address:
  • Phone: 915-854-4304
  • Fax: 817-533-9430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3558896
License Number StateZZ

VIII. Authorized Official

Name: MS. BERTHA NUNEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 011826566116561