Provider Demographics
NPI:1376083808
Name:VILLANUEVA, JORGE A (DDS)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:A
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 E COLORADO BLVD APT 705
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1257
Mailing Address - Country:US
Mailing Address - Phone:469-585-0755
Mailing Address - Fax:
Practice Address - Street 1:329 E COLORADO BLVD APT 705
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1257
Practice Address - Country:US
Practice Address - Phone:469-585-0755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX326911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice