Healthcare Provider Details

I. General information

NPI: 1891929675
Provider Name (Legal Business Name): INNOVATION ORTHODONTIC AND DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2009
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALVARO OBREGON #31
NOGALES SONORA
84030
MX

IV. Provider business mailing address

PO BOX 12385
EL PASO TX
79913-0385
US

V. Phone/Fax

Practice location:
  • Phone: 526313128817
  • Fax:
Mailing address:
  • Phone: 915-726-0929
  • Fax: 915-585-9833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5248853
License Number StateZZ

VIII. Authorized Official

Name: LUIS F ISLAS
Title or Position: ADMINISTRATOR
Credential:
Phone: 915-726-0929