Healthcare Provider Details

I. General information

NPI: 1598846347
Provider Name (Legal Business Name): JULIO C DE LA FUENTE DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 10/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 S MCCOLL RD
EDINBURG TX
78539-9183
US

IV. Provider business mailing address

5405 S MCCOLL RD
EDINBURG TX
78539-9183
US

V. Phone/Fax

Practice location:
  • Phone: 956-668-1780
  • Fax: 956-668-1781
Mailing address:
  • Phone: 956-668-1780
  • Fax: 956-668-1781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19788
License Number StateTX

VIII. Authorized Official

Name: DR. JULIO CESAR DE LA FUENTE JR.
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 956-668-1780