Provider Demographics
NPI:1760054688
Name:MEDEIROS LIMA, FREDERICO DIEGO (DDS)
Entity Type:Individual
Prefix:DR
First Name:FREDERICO
Middle Name:DIEGO
Last Name:MEDEIROS LIMA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:FREDERICO
Other - Middle Name:DIEGO
Other - Last Name:LIMA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2520 MEADOWGLEN CT
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-6283
Mailing Address - Country:US
Mailing Address - Phone:602-748-7137
Mailing Address - Fax:
Practice Address - Street 1:921 SHILOH RD STE A100
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1402
Practice Address - Country:US
Practice Address - Phone:903-581-1777
Practice Address - Fax:903-581-1781
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX370761223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics