Healthcare Provider Details

I. General information

NPI: 1477921369
Provider Name (Legal Business Name): LUIS GERARDO VALDEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE COAHUILA #223 SUITE 9B
NUEVO PROGRESO TAMAULIPAS
88810
MX

IV. Provider business mailing address

CALLE COAHUILA #223 SUITE 9B
NUEVO PROGRESO TAMAULIPAS
88810
MX

V. Phone/Fax

Practice location:
  • Phone: 956-279-4009
  • Fax:
Mailing address:
  • Phone: 956-279-4009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number928023
License Number StateZZ

VIII. Authorized Official

Name: LUIS GERARDO VALDEZ
Title or Position: OWNER
Credential: DDS
Phone: 956-279-4009