Healthcare Provider Details

I. General information

NPI: 1558049387
Provider Name (Legal Business Name): DIEGO IGNACIO FERNANDEZ VIAL DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12626 WOODFOREST BLVD STE Z
HOUSTON TX
77015-3653
US

IV. Provider business mailing address

1916 W GRAY ST APT 240
HOUSTON TX
77019-4834
US

V. Phone/Fax

Practice location:
  • Phone: 171-359-0099
  • Fax:
Mailing address:
  • Phone: 859-382-3910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number39810
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: