Healthcare Provider Details

I. General information

NPI: 1801497532
Provider Name (Legal Business Name): TRINITY LAREDO DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 CLARK BLVD STE O
LAREDO TX
78043-4167
US

IV. Provider business mailing address

507 N SAM HOUSTON PKWY E STE 555
HOUSTON TX
77060-4021
US

V. Phone/Fax

Practice location:
  • Phone: 956-539-2979
  • Fax: 832-532-1904
Mailing address:
  • Phone: 832-648-7632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. RUBEN LOPEZ
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 832-648-7632