Provider Demographics
NPI:1659811248
Name:AVILA PANDO, VIANNEY M
Entity Type:Individual
Prefix:
First Name:VIANNEY
Middle Name:M
Last Name:AVILA PANDO
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 1:5848 ANGEL ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79932-4218
Mailing Address - Country:US
Mailing Address - Phone:915-422-1333
Mailing Address - Fax:
Practice Address - Street 1:CALLE ZEMPOALA 3410
Practice Address - Street 2:2DO PISO
Practice Address - City:JUAREZ
Practice Address - State:CHIHUAHUA
Practice Address - Zip Code:CP32310
Practice Address - Country:MX
Practice Address - Phone:915-356-7597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ4260467122300000X, 1223G0001X, 1223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology