Basic Information
| Provider Information | |||||||||
| NPI: | 1881150894 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN DARIO AVENUE DENTAL, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 E MCKINNEY ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762097557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9402207833 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4817 SAN DARIO AVE | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780415754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9402207833 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2019 | ||||||||
| LastUpdateDate: | 02/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | EVERETT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/ DDS | ||||||||
| AuthorizedOfficialTelephone: | 9402207833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.