Healthcare Provider Details

I. General information

NPI: 1326290701
Provider Name (Legal Business Name): FD SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HEROE DE NACATAZ # 2111 ALTOS
NUEVO LAREDO TAMPS
88000
MX

IV. Provider business mailing address

4619 SAN DARIO AVE # 224
LAREDO TX
78041-5773
US

V. Phone/Fax

Practice location:
  • Phone: 867-713-1314
  • Fax:
Mailing address:
  • Phone: 956-727-0497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3139088
License Number StateZZ

VIII. Authorized Official

Name: DR. AMIRA CARMONA
Title or Position: OWNER
Credential: DDS
Phone: 956-727-0497