Provider Demographics
NPI:1700113537
Name:DENTAL LASER & IMPLANT GROUP
Entity Type:Organization
Organization Name:DENTAL LASER & IMPLANT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BERTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:01182656-611-6561
Mailing Address - Street 1:7101 N. MESA
Mailing Address - Street 2:#538
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912
Mailing Address - Country:US
Mailing Address - Phone:915-854-4304
Mailing Address - Fax:817-533-9430
Practice Address - Street 1:CENTRO EJECTIVO PLAZA JUAREZ LINCOLN
Practice Address - Street 2:#205
Practice Address - City:CD. JUAREZ
Practice Address - State:CHIH
Practice Address - Zip Code:36310
Practice Address - Country:MX
Practice Address - Phone:01152656-611-6561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ35588961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty