Provider Demographics
NPI:1659686467
Name:DEWBERRY, LATRESA
Entity Type:Individual
Prefix:
First Name:LATRESA
Middle Name:
Last Name:DEWBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 VIA BRAVO
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-3017
Mailing Address - Country:US
Mailing Address - Phone:469-879-3396
Mailing Address - Fax:214-613-2592
Practice Address - Street 1:705 VIA BRAVO
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-3017
Practice Address - Country:US
Practice Address - Phone:469-879-3396
Practice Address - Fax:214-613-2592
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor