Healthcare Provider Details

I. General information

NPI: 1710232665
Provider Name (Legal Business Name): BORDER DENTAL BILLING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SANTOS DEGOLLADO 3343
NUEVO LAREDO TAMAULIPAS
88240
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: 956-523-8701
  • Fax: 956-523-8701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3291593
License Number StateZZ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3395326
License Number StateZZ
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number3395326
License Number StateZZ
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3395326
License Number StateZZ

VIII. Authorized Official

Name: DR. LUIS MIGUEL TREVINO
Title or Position: PRESIDENT/ORTHODONTIST
Credential: D.D.S
Phone: 956-523-8701