Provider Demographics
NPI:1912156100
Name:LATIOLAIS, TREY MATTHEW (DDS)
Entity Type:Individual
Prefix:
First Name:TREY
Middle Name:MATTHEW
Last Name:LATIOLAIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 BROADNAX STREET
Mailing Address - Street 2:
Mailing Address - City:DAINGERFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:75638
Mailing Address - Country:US
Mailing Address - Phone:903-645-7335
Mailing Address - Fax:903-645-7336
Practice Address - Street 1:1106 BROADNAX STREET
Practice Address - Street 2:
Practice Address - City:DAINGERFIELD
Practice Address - State:TX
Practice Address - Zip Code:75638
Practice Address - Country:US
Practice Address - Phone:903-645-7335
Practice Address - Fax:903-645-7336
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX240311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice