Healthcare Provider Details

I. General information

NPI: 1912156100
Provider Name (Legal Business Name): TREY MATTHEW LATIOLAIS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 BROADNAX STREET
DAINGERFIELD TX
75638
US

IV. Provider business mailing address

1106 BROADNAX STREET
DAINGERFIELD TX
75638
US

V. Phone/Fax

Practice location:
  • Phone: 903-645-7335
  • Fax: 903-645-7336
Mailing address:
  • Phone: 903-645-7335
  • Fax: 903-645-7336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number24031
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: