Provider Demographics
NPI:1578793055
Name:PEREZ, JUVENCIO C IV (DDS)
Entity Type:Individual
Prefix:
First Name:JUVENCIO
Middle Name:C
Last Name:PEREZ
Suffix:IV
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 EVERHART ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-1999
Mailing Address - Country:US
Mailing Address - Phone:361-992-9871
Mailing Address - Fax:361-334-5983
Practice Address - Street 1:737 EVERHART ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1999
Practice Address - Country:US
Practice Address - Phone:361-992-9871
Practice Address - Fax:361-334-5983
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX247851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171353904Medicaid
TX171353905Medicaid
TX171353901Medicaid