Provider Demographics
NPI:1891929675
Name:INNOVATION ORTHODONTIC AND DENTAL CENTER
Entity Type:Organization
Organization Name:INNOVATION ORTHODONTIC AND DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:F
Authorized Official - Last Name:ISLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-726-0929
Mailing Address - Street 1:PO BOX 12385
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79913-0385
Mailing Address - Country:US
Mailing Address - Phone:915-726-0929
Mailing Address - Fax:915-585-9833
Practice Address - Street 1:ALVARO OBREGON #31
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:SONORA
Practice Address - Zip Code:84030
Practice Address - Country:MX
Practice Address - Phone:52631-312-8817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-08
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ5248853122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty