Provider Demographics
NPI:1346783776
Name:N/A
Entity Type:Organization
Organization Name:N/A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICO CIRUJANO DENTISTA
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:SEGOVIANO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:956-282-6182
Mailing Address - Street 1:1221 BROWN DR
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-8382
Mailing Address - Country:US
Mailing Address - Phone:956-282-6182
Mailing Address - Fax:
Practice Address - Street 1:AV. TECNOLOGICO 183
Practice Address - Street 2:
Practice Address - City:NUEVO LAREDO
Practice Address - State:TAMAULIPAS
Practice Address - Zip Code:88275
Practice Address - Country:MX
Practice Address - Phone:867-717-5390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-03
Last Update Date:2016-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ9352611302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization