=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568600948
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NAVARRO ORTHODONTICS RGC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2009
-----------------------------------------------------
Last Update Date | 01/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5322 E US HIGHWAY 83 STE C2
-----------------------------------------------------
City | RIO GRANDE CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78582-9461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-458-9324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5322 E US HIGHWAY 83 STE C2
-----------------------------------------------------
City | RIO GRANDE CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78582-9461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARCO A NAVARRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-458-9324
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 14228
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------