Provider Demographics
NPI:1093897951
Name:RIO GRANDE VALLEY CHILDREN'S DENTISTRY
Entity Type:Organization
Organization Name:RIO GRANDE VALLEY CHILDREN'S DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:HECTOR
Authorized Official - Last Name:TREVINO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-781-8880
Mailing Address - Street 1:413 W SAM HOUSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-5349
Mailing Address - Country:US
Mailing Address - Phone:956-781-8880
Mailing Address - Fax:956-781-8977
Practice Address - Street 1:413 W SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-5349
Practice Address - Country:US
Practice Address - Phone:956-781-8880
Practice Address - Fax:956-781-8977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161103001Medicaid