Provider Demographics
NPI:1245699974
Name:GARDUNO COGOLLOR, SIXTO (DMD)
Entity type:Individual
Prefix:
First Name:SIXTO
Middle Name:
Last Name:GARDUNO COGOLLOR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 CHESTERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:VENUS
Mailing Address - State:TX
Mailing Address - Zip Code:76084-3661
Mailing Address - Country:US
Mailing Address - Phone:787-236-8565
Mailing Address - Fax:
Practice Address - Street 1:820 ANN AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75223-2716
Practice Address - Country:US
Practice Address - Phone:214-590-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0408781223G0001X
TX355941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice