Healthcare Provider Details

I. General information

NPI: 1619332830
Provider Name (Legal Business Name): DR. FERNANDO JAVIER SAMANO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LAZARO CARDENAS LOC. 27 PLAZA LAS AMERICAS CENTRO
REYNOSA TAMAULIPAS
88500
MX

IV. Provider business mailing address

501 N BRIDGE ST # 200
HIDALGO TX
78557-2530
US

V. Phone/Fax

Practice location:
  • Phone: 956-655-3535
  • Fax:
Mailing address:
  • Phone: 956-655-3535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1060672
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: