Healthcare Provider Details

I. General information

NPI: 1881920163
Provider Name (Legal Business Name): PREMIER DENTAL SEGUIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2009
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W CEDAR ST
SEGUIN TX
78155-3748
US

IV. Provider business mailing address

104 W CEDAR ST
SEGUIN TX
78155-3748
US

V. Phone/Fax

Practice location:
  • Phone: 830-379-9310
  • Fax: 830-401-0230
Mailing address:
  • Phone: 830-379-9310
  • Fax: 830-401-0230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22462
License Number StateTX

VIII. Authorized Official

Name: LUIGI O MASSA
Title or Position: OWNER
Credential:
Phone: 830-625-2111