Healthcare Provider Details

I. General information

NPI: 1609008093
Provider Name (Legal Business Name): JAIME PUERTAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PEDRO S. VARELA 3003-11
CD. JUAREZ CHIHUAHUA
32310
MX

IV. Provider business mailing address

PO BOX 12385
EL PASO TX
79913-0385
US

V. Phone/Fax

Practice location:
  • Phone: 526566160926
  • Fax:
Mailing address:
  • Phone: 915-449-8589
  • Fax: 915-239-2212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number565940
License Number StateZZ

VIII. Authorized Official

Name: JAIME F. PUERTAS
Title or Position: OWNER
Credential: DDS
Phone: 915-726-0929