Healthcare Provider Details

I. General information

NPI: 1740006899
Provider Name (Legal Business Name): LUIS CARLOS MUNGUIA DENTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 AVENIDA KINO 5 Y 6
SAN LUIS SONORA
83449
MX

IV. Provider business mailing address

PO BOX 624
SAN LUIS AZ
85349-0624
US

V. Phone/Fax

Practice location:
  • Phone: 653-534-5515
  • Fax:
Mailing address:
  • Phone: 653-534-1515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number1751642
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1751642
License Number StateZZ
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1751642
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number1751642
License Number StateZZ
# 5
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number1751642
License Number StateZZ
# 6
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1751642
License Number StateZZ
# 7
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number1751642
License Number StateAZ
# 8
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number1751642
License Number StateZZ
# 9
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1751642
License Number StateZZ
# 10
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number1751642
License Number StateAZ
# 11
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number1751642
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: