MEDICARE: DEMITRI VILLARREAL D.D.S.; M.S.

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	390200000X	Student in an Organized Health Care Education/Training Program	A000986496	TX
2	1223P0300X	Periodontics	23464	TX
3	1223P0300X	Periodontics	S4-97C	NV

General Provider Information

NPI Number	:	1588865943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEMITRI VILLARREAL D.D.S.; M.S.

Provider Business Mailing Address
First Line	:	2133 PEPPERRELL ST
Second Line	:
City	:	LACKLAND AFB
State	:	TX
Zip	:	78236-5313
Country	:	US
Telephone Number	:	210-292-2558
Fax Number	:

Provider Business Practice Location Address
First Line	:	2133 PEPPERRELL ST
Second Line	:
City	:	LACKLAND AFB
State	:	TX
Zip	:	78236-5313
Country	:	US
Telephone Number	:	210-292-2558
Fax Number	:

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

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	04/30/2018

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