Provider Demographics
NPI:1518145648
Name:CITY OF LAREDO HEALTH DEPARTMENT DENTAL CLINIC
Entity Type:Organization
Organization Name:CITY OF LAREDO HEALTH DEPARTMENT DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:GUEST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-450-3318
Mailing Address - Street 1:PO BOX 40397
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-1397
Mailing Address - Country:US
Mailing Address - Phone:210-567-3274
Mailing Address - Fax:210-567-2844
Practice Address - Street 1:2600 CEDAR
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78044-2337
Practice Address - Country:US
Practice Address - Phone:956-795-4900
Practice Address - Fax:956-726-2632
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UTHSCSA DENTAL SCHOOL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-31
Last Update Date:2018-01-25
Deactivation Date:2017-10-09
Deactivation Code:
Reactivation Date:2017-10-24
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental