Healthcare Provider Details

I. General information

NPI: 1245482702
Provider Name (Legal Business Name): CARLOS GUSTAVO CUELLAR DENTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3307 FRANCISCO MINA
NUEVO LAREDO TAMAULIPAS
88000
MX

IV. Provider business mailing address

4530 RODEO LN
LAREDO TX
78046-7522
US

V. Phone/Fax

Practice location:
  • Phone: 867-187-0663
  • Fax:
Mailing address:
  • Phone: 956-753-7752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5163772
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: