Provider Demographics
NPI:1205223260
Name:VALDES, MARIO S
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:S
Last Name:VALDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 TAMARRON BLVD
Mailing Address - Street 2:APT 2301
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-8035
Mailing Address - Country:US
Mailing Address - Phone:512-496-3732
Mailing Address - Fax:
Practice Address - Street 1:7517 CAMERON RD
Practice Address - Street 2:SUITE 106
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-2057
Practice Address - Country:US
Practice Address - Phone:512-278-1232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX303871223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics