Healthcare Provider Details

I. General information

NPI: 1700159266
Provider Name (Legal Business Name): JORGE A. FLORES D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2840 MORELOS
NUEVO LAREDO TAMAULIPAS
88000
MX

IV. Provider business mailing address

PO BOX 2242
LAREDO TX
78044-2242
US

V. Phone/Fax

Practice location:
  • Phone: 956-740-9444
  • Fax:
Mailing address:
  • Phone: 956-740-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1403391
License Number StateZZ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberAE-008082
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: