Healthcare Provider Details

I. General information

NPI: 1083055735
Provider Name (Legal Business Name): FERNANDO DE LA ROSA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVENIDA BENITO JUAREZ #115 2
NUEVO PROGRESO TAMAULIPAS
88810
MX

IV. Provider business mailing address

AVENIDA BENITO JUAREZ #115 2
NUEVO PROGRESO TAMAULIPAS
88810
MX

V. Phone/Fax

Practice location:
  • Phone: 011528999371471
  • Fax:
Mailing address:
  • Phone: 011528999371471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1721141
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: