MEDICARE: LUIS YASSER VILLAVICENCIO MENDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	39082	TX

General Provider Information

NPI Number	:	1376267120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS YASSER VILLAVICENCIO MENDEZ

Provider Business Mailing Address
First Line	:	10300 CYPRESSWOOD DR APT 324
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-6501
Country	:	US
Telephone Number	:	786-539-9117
Fax Number	:

Provider Business Practice Location Address
First Line	:	13327 TOMBALL PKWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77086-3128
Country	:	US
Telephone Number	:	281-940-3086
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2022
Last Update Date	:	09/26/2022

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Directions to “ LUIS YASSER VILLAVICENCIO MENDEZ ” Practice Location

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