Provider Demographics
NPI:1124357181
Name:PRO DENT RIO BRAVO S. DE R.L DE C.V.
Entity Type:Organization
Organization Name:PRO DENT RIO BRAVO S. DE R.L DE C.V.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:FERNANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:52656-616-5689
Mailing Address - Street 1:279 SHADOW MTN DR # 229
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-4707
Mailing Address - Country:US
Mailing Address - Phone:656-616-5689
Mailing Address - Fax:
Practice Address - Street 1:AV. ABRAHAM LINCOLN 201, LA PLAYA
Practice Address - Street 2:
Practice Address - City:CD. JUAREZ
Practice Address - State:CHIH
Practice Address - Zip Code:32317
Practice Address - Country:MX
Practice Address - Phone:52656-616-5689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty