=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801384623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAREDO LHPD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2018
-----------------------------------------------------
Last Update Date | 04/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5220 MCPHERSON RD STE 101
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-7323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-910-1078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7029 N 1ST ST
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-1929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRIC DENTIST
-----------------------------------------------------
Name | ALEGRA VIRELLA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 215-205-5516
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 24607
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------