Healthcare Provider Details

I. General information

NPI: 1346783776
Provider Name (Legal Business Name): N/A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2016
Last Update Date: 12/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AV. TECNOLOGICO 183
NUEVO LAREDO TAMAULIPAS
88275
MX

IV. Provider business mailing address

1221 BROWN DR
LAREDO TX
78045-8382
US

V. Phone/Fax

Practice location:
  • Phone: 867-717-5390
  • Fax:
Mailing address:
  • Phone: 956-282-6182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number9352611
License Number StateZZ

VIII. Authorized Official

Name: DR. JUAN ANTONIO SEGOVIANO JR.
Title or Position: MEDICO CIRUJANO DENTISTA
Credential:
Phone: 956-282-6182