Healthcare Provider Details

I. General information

NPI: 1669030979
Provider Name (Legal Business Name): ANGELA PATRICIA VELASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2019
Last Update Date: 06/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 RIALTO BLVD APT 6213
AUSTIN TX
78735-0063
US

IV. Provider business mailing address

6601 RIALTO BLVD APT 6213
AUSTIN TX
78735-0063
US

V. Phone/Fax

Practice location:
  • Phone: 512-720-1323
  • Fax:
Mailing address:
  • Phone: 512-720-1323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1143824335
License Number StateZZ
# 2
Primary TaxonomyN
Taxonomy Code126900000X
TaxonomyDental Laboratory Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: