Healthcare Provider Details

I. General information

NPI: 1891439584
Provider Name (Legal Business Name): JUAN CARLOS LLARENA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7002 NE ZAC LENTZ PKWY
VICTORIA TX
77904-3450
US

IV. Provider business mailing address

7002 NE ZAC LENTZ PKWY
VICTORIA TX
77904-3450
US

V. Phone/Fax

Practice location:
  • Phone: 361-214-3683
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22094
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22094
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: