MEDICARE: DR. ROBERTO VELASCO 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	122300000X	Dentist	21195	TX

General Provider Information

NPI Number	:	1659474294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERTO VELASCO DDS

Provider Business Mailing Address
First Line	:	2425 WEST LOOP S
Second Line	:	STE 333
City	:	HOUSTON
State	:	TX
Zip	:	77027-4205
Country	:	US
Telephone Number	:	713-960-9623
Fax Number	:	713-960-8682

Provider Business Practice Location Address
First Line	:	2425 WEST LOOP S
Second Line	:	STE 333
City	:	HOUSTON
State	:	TX
Zip	:	77027-4205
Country	:	US
Telephone Number	:	713-960-9623
Fax Number	:	713-960-8682

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

Provider Enumeration Date	:	09/07/2006
Last Update Date	:	12/09/2015

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