Provider Demographics
NPI:1245425552
Name:WELCH, KERMIT NEVARO (DDS MSD)
Entity Type:Individual
Prefix:
First Name:KERMIT
Middle Name:NEVARO
Last Name:WELCH
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 SOUTH L B J DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666
Mailing Address - Country:US
Mailing Address - Phone:512-139-6800
Mailing Address - Fax:512-396-8008
Practice Address - Street 1:321 SOUTH L B J DRIVE
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666
Practice Address - Country:US
Practice Address - Phone:512-139-6800
Practice Address - Fax:512-396-8008
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75891223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D07589OtherBLUE CROSS BLUE SHIELD
803444OtherUNITED CONCORDIA