Provider Demographics
NPI:1568143329
Name:PEREZ FRUTOS, JORGE RAUL
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:RAUL
Last Name:PEREZ FRUTOS
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 1:11425 FLOR LIATRIS DR
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:TX
Mailing Address - Zip Code:79927-3393
Mailing Address - Country:US
Mailing Address - Phone:915-215-9491
Mailing Address - Fax:
Practice Address - Street 1:AVENIDA DE LA RAZA #4347
Practice Address - Street 2:
Practice Address - City:JUAREZ
Practice Address - State:CHIHUAHUA
Practice Address - Zip Code:32350
Practice Address - Country:MX
Practice Address - Phone:915-215-9491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75458771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty