Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 3223659 | ZZ |
NPI | 1003266644 |
---|---|
Provider Name | Dr. Mario Ruiz |
First Address | Brownsville, TX 78526-1897 |
Second Address | Matamoros, TAMAULIPAS 87330 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2016 |
Last Update Date | 14/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
16963758 | AETENA, BLUE CROSS ETC (01) | TX |