Healthcare Provider Details

I. General information

NPI: 1013137082
Provider Name (Legal Business Name): DENTAL WATERFILL SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 SABOROSA AVE
SABAROSA CHIH
32550
MX

IV. Provider business mailing address

1120 WILL RAND DR
EL PASO TX
79912-7620
US

V. Phone/Fax

Practice location:
  • Phone: 011526566820117
  • Fax:
Mailing address:
  • Phone: 915-449-8589
  • Fax: 915-833-8796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2988099
License Number StateTX

VIII. Authorized Official

Name: GUILLERMO FEUCHTER
Title or Position: GENERAL PARTNER
Credential:
Phone: 011526566820118