Provider Demographics
NPI:1467052613
Name:LABASTIDA TORRES, VALERIA
Entity Type:Individual
Prefix:
First Name:VALERIA
Middle Name:
Last Name:LABASTIDA TORRES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 WAVERLY CV
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-0669
Mailing Address - Country:US
Mailing Address - Phone:817-734-6025
Mailing Address - Fax:
Practice Address - Street 1:1955 N COBB PKWY STE 110
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4503
Practice Address - Country:US
Practice Address - Phone:770-799-8964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN1226141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program