Provider Demographics
NPI:1841370764
Name:FUENTES, EDUARDO TORIBIO (LSA)
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:TORIBIO
Last Name:FUENTES
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11214 N COUNTRY CLUB GREEN DRIVE
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375
Mailing Address - Country:US
Mailing Address - Phone:281-703-2727
Mailing Address - Fax:
Practice Address - Street 1:11214 N COUNTRY CLUB GREEN DRIVE
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375
Practice Address - Country:US
Practice Address - Phone:281-703-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00275246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist