Healthcare Provider Details

I. General information

NPI: 1598040057
Provider Name (Legal Business Name): LUIS MIGUEL TREVINO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 07/13/2012
Certification Date: TREVINO LUIS MIGUEL 110 CARDINAL LN LAREDO TX 78045 SANTOS DEGOLLADO 3343 NUEVO LAREDO 888240
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SANTOS DEGOLLADO 3343
NUEVO LAREDO
888240
MX

IV. Provider business mailing address

110 CARDINAL LN
LAREDO TX
78045-4150
US

V. Phone/Fax

Practice location:
  • Phone: 956-242-4147
  • Fax:
Mailing address:
  • Phone: 956-237-2858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics
License Number3395326
License Number StateZZ
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice
License Number3395326
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: