MEDICARE: MR. EDUARDO AVILES

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	124Q00000X	Dental Hygienist	11478	TX

General Provider Information

NPI Number	:	1710122379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDUARDO AVILES

Provider Business Mailing Address
First Line	:	PO BOX 2176
Second Line	:
City	:	FABENS
State	:	TX
Zip	:	79838-2176
Country	:	US
Telephone Number	:	915-855-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3110 TRAWOOD DR
Second Line	:	SUITE D
City	:	EL PASO
State	:	TX
Zip	:	79936-4394
Country	:	US
Telephone Number	:	915-855-1000
Fax Number	:

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

Provider Enumeration Date	:	12/11/2008
Last Update Date	:	12/11/2008

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