Provider Demographics
NPI:1598071680
Name:VALLABHBHAI, POONAM (DDS)
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:VALLABHBHAI
Suffix:
Gender:F
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:PO BOX 1470
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78853-1470
Mailing Address - Country:US
Mailing Address - Phone:830-773-6963
Mailing Address - Fax:830-757-5647
Practice Address - Street 1:2525 N VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-3302
Practice Address - Country:US
Practice Address - Phone:830-773-5358
Practice Address - Fax:830-773-0328
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00258491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX25849OtherTX STATE BOARD OF DENTAL EXAMINERS - DDS LICENSE