Provider Demographics
NPI:1578980900
Name:ENRIQUE MORENO
Entity Type:Organization
Organization Name:ENRIQUE MORENO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:915-726-0929
Mailing Address - Street 1:PO BOX 12385
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79913-0385
Mailing Address - Country:US
Mailing Address - Phone:915-449-8589
Mailing Address - Fax:
Practice Address - Street 1:AVE. OBREGON #72
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:SONORA
Practice Address - Zip Code:84000
Practice Address - Country:MX
Practice Address - Phone:520-285-7385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ1401922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty