Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 14393 | TX |
NPI | 1013010453 |
---|---|
Provider Name | Dr. Serapio De La Rosa JR. |
First Address | San Benito, TX 78586 |
Second Address | San Benito, TX 78586 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2006 |
Last Update Date | 23/04/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
TPI111234402 | (05) | TX |