Healthcare Provider Details

I. General information

NPI: 1205386992
Provider Name (Legal Business Name): GRACIELA URBINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

O CAMPO 3147
NVO LAREDO TAMPS
88260
MX

IV. Provider business mailing address

1636 DENMARK LN
LAREDO TX
78045-8389
US

V. Phone/Fax

Practice location:
  • Phone: 867-196-2792
  • Fax:
Mailing address:
  • Phone: 956-285-8141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4452790
License Number StateZZ
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1791300
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: