Healthcare Provider Details

I. General information

NPI: 1427194364
Provider Name (Legal Business Name): TRENT CECIL FILLER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 ALBERTA AVE
EL PASO TX
79905-2709
US

IV. Provider business mailing address

PO BOX 9520
EL PASO TX
79995-9520
US

V. Phone/Fax

Practice location:
  • Phone: 915-594-3584
  • Fax:
Mailing address:
  • Phone: 915-545-6954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDD2840
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1160
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12562
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberT2400
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: