Healthcare Provider Details

I. General information

NPI: 1710259650
Provider Name (Legal Business Name): AGUILERA LASER DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE. MIGUEL ALEMAN 1125 ZONA CENTRO
REYNOSA TAMAULIPAS
88510
MX

IV. Provider business mailing address

425 E COMA AVE SUITE 315
HIDALGO TX
78557-2508
US

V. Phone/Fax

Practice location:
  • Phone: 011528999224700
  • Fax:
Mailing address:
  • Phone: 956-827-2636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5285364
License Number StateZZ

VIII. Authorized Official

Name: DR. OMAR UBALDO AGUILERA
Title or Position: OWNER/DENTIST
Credential: D.D.S.
Phone: 956-827-2636