Provider Demographics
NPI:1457853137
Name:LEZAMA DE SOLAR, GUADALUPE (RDH)
Entity Type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:
Last Name:LEZAMA DE SOLAR
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2018 W RUNDBERG LN APT 13D
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5973
Mailing Address - Country:US
Mailing Address - Phone:979-219-6084
Mailing Address - Fax:
Practice Address - Street 1:2411 WILLIAMS DR STE 111
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-3268
Practice Address - Country:US
Practice Address - Phone:512-864-1445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14868124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist