Provider Demographics
NPI:1104956630
Name:SAINT JOSEPH ORAL & MAXILLOFACIAL
Entity type:Organization
Organization Name:SAINT JOSEPH ORAL & MAXILLOFACIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CESAR
Authorized Official - Middle Name:
Authorized Official - Last Name:TREVINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-795-1010
Mailing Address - Street 1:1519 E BUSTAMANTE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-5305
Mailing Address - Country:US
Mailing Address - Phone:956-795-1010
Mailing Address - Fax:956-795-1040
Practice Address - Street 1:1519 E BUSTAMANTE ST
Practice Address - Street 2:SUITE B
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-5305
Practice Address - Country:US
Practice Address - Phone:956-795-1010
Practice Address - Fax:956-795-1040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00812YMedicare ID - Type Unspecified