Healthcare Provider Details

I. General information

NPI: 1417480369
Provider Name (Legal Business Name): BORDER DENTAL CENTER DE NUEVO LAREDO SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SANTOS DEGOLLADO 2229 COLONIA GUERRERO
NUEVO LAREDO TAMAULIPAS
88240
MX

IV. Provider business mailing address

1806 COMMERCE DR STE 203
LAREDO TX
78041-2884
US

V. Phone/Fax

Practice location:
  • Phone: 956-242-4144
  • Fax:
Mailing address:
  • Phone: 956-645-9738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number1150654
License Number StateZZ

VIII. Authorized Official

Name: DR. GRACIELA VILLANUEVA
Title or Position: DENTIST
Credential: M.D.S
Phone: 956-645-9738