Provider Demographics
NPI:1619196581
Name:LATINO, CHAD J (DDS)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:J
Last Name:LATINO
Suffix:
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 1:6701 SANGER AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-7736
Mailing Address - Country:US
Mailing Address - Phone:254-776-6241
Mailing Address - Fax:254-776-6017
Practice Address - Street 1:6701 SANGER AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-7736
Practice Address - Country:US
Practice Address - Phone:254-776-6241
Practice Address - Fax:254-776-6017
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166291801Medicaid