Provider Demographics
NPI:1376267120
Name:VILLAVICENCIO MENDEZ, LUIS YASSER
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:YASSER
Last Name:VILLAVICENCIO MENDEZ
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 1:10300 CYPRESSWOOD DR APT 324
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-6501
Mailing Address - Country:US
Mailing Address - Phone:786-539-9117
Mailing Address - Fax:
Practice Address - Street 1:13327 TOMBALL PKWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77086-3128
Practice Address - Country:US
Practice Address - Phone:281-940-3086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice