Healthcare Provider Details

I. General information

NPI: 1154791846
Provider Name (Legal Business Name): OLMITO FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7097 N EXPRESSWAY 77 SUITE 10
OLMITO TX
78575-9807
US

IV. Provider business mailing address

7097 N EXPRESSWAY 77 SUITE 10
OLMITO TX
78575-9807
US

V. Phone/Fax

Practice location:
  • Phone: 830-328-6310
  • Fax:
Mailing address:
  • Phone: 830-328-6310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number26262
License Number StateTX

VIII. Authorized Official

Name: DR. GONZALO BRAUNTHAL
Title or Position: OWNER / GENERAL DENTIST
Credential: DMD
Phone: 830-328-6310