Provider Demographics
NPI:1104364165
Name:EDINBURG DENTAL, PLLC
Entity Type:Organization
Organization Name:EDINBURG DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:GUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-537-6764
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-0102
Mailing Address - Country:US
Mailing Address - Phone:956-537-6764
Mailing Address - Fax:
Practice Address - Street 1:423 W FM 495
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-3717
Practice Address - Country:US
Practice Address - Phone:956-537-6764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226441223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX802626200Medicaid