Provider Demographics
NPI:1609049527
Name:GUZMAN PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:GUZMAN PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:GUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-581-4403
Mailing Address - Street 1:1317 ST CLAIRE BLVD STE A3
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-6636
Mailing Address - Country:US
Mailing Address - Phone:956-581-4403
Mailing Address - Fax:956-581-2242
Practice Address - Street 1:1317 ST CLAIRE BLVD STE A3
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-6636
Practice Address - Country:US
Practice Address - Phone:956-581-4403
Practice Address - Fax:956-581-2242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226441223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193025701Medicaid