MEDICARE: RENE JOAQUIN DE LA FUENTE JR DDS

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	12428	TX

General Provider Information

NPI Number	:	1528278173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENE JOAQUIN DE LA FUENTE JR DDS

Provider Business Mailing Address
First Line	:	1512 N ZARAGOSA ST
Second Line	:	SUITE C-1
City	:	EL PASO
State	:	TX
Zip	:	79936
Country	:	US
Telephone Number	:	915-591-2525
Fax Number	:	915-592-4083

Provider Business Practice Location Address
First Line	:	1512 N ZARAGOSA ST
Second Line	:	SUITE C-1
City	:	EL PASO
State	:	TX
Zip	:	79936
Country	:	US
Telephone Number	:	915-591-2525
Fax Number	:	915-592-4083

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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