Provider Demographics
NPI:1386823912
Name:VELASQUEZ, LINA M (DDS)
Entity Type:Individual
Prefix:
First Name:LINA
Middle Name:M
Last Name:VELASQUEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2337 S BELTLINE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051
Mailing Address - Country:US
Mailing Address - Phone:972-282-9444
Mailing Address - Fax:972-282-9446
Practice Address - Street 1:2337 S BELT LINE RD STE 100
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-4152
Practice Address - Country:US
Practice Address - Phone:972-282-9444
Practice Address - Fax:972-282-9446
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56361122300000X
TX248891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX205094012Medicaid
CA56361OtherSTATE OF CALIFORNIA