Provider Demographics
NPI:1447622907
Name:EDGAR PEREZ
Entity type:Organization
Organization Name:EDGAR PEREZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:ZAID
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-239-5910
Mailing Address - Street 1:PO BOX 8490
Mailing Address - Street 2:PMB 206
Mailing Address - City:SAN LUIS
Mailing Address - State:AZ
Mailing Address - Zip Code:85349-6829
Mailing Address - Country:US
Mailing Address - Phone:928-239-5910
Mailing Address - Fax:
Practice Address - Street 1:C. 2DA Y CAALLEJON INTERNACIONAL #200-4
Practice Address - Street 2:
Practice Address - City:SAN LUIS RIO COLORADO
Practice Address - State:SONORA
Practice Address - Zip Code:83450
Practice Address - Country:MX
Practice Address - Phone:928-239-5910
Practice Address - Fax:858-430-3143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ54969351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty