Provider Demographics
NPI:1205386992
Name:URBINA, GRACIELA
Entity Type:Individual
Prefix:
First Name:GRACIELA
Middle Name:
Last Name:URBINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 DENMARK LN
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-8389
Mailing Address - Country:US
Mailing Address - Phone:956-285-8141
Mailing Address - Fax:
Practice Address - Street 1:O CAMPO 3147
Practice Address - Street 2:
Practice Address - City:NVO LAREDO
Practice Address - State:TAMPS
Practice Address - Zip Code:88260
Practice Address - Country:MX
Practice Address - Phone:867-196-2792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ44527901223E0200X
ZZ17913001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223E0200XDental ProvidersDentistEndodontics