Healthcare Provider Details

I. General information

NPI: 1063375517
Provider Name (Legal Business Name): OMAR NOE REYES CORDERO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE MELQUIADES ALANIS #6211
CD. JUAREZ CHUHUAHUA
32320
MX

IV. Provider business mailing address

11964 MEDALLA ST
EL PASO TX
79927
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 915-215-9491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: