Provider Demographics
NPI:1043820590
Name:VELASQUEZ, RONALD MAURICIO (DDS)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:MAURICIO
Last Name:VELASQUEZ
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 1:614 N ROGERS RD
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-7246
Mailing Address - Country:US
Mailing Address - Phone:469-826-7591
Mailing Address - Fax:
Practice Address - Street 1:611 N BISHOP AVE STE 102
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4361
Practice Address - Country:US
Practice Address - Phone:214-948-3035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-08
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36495122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist