Provider Demographics
NPI:1881745495
Name:AVILA, JUAN (DDS)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:
Last Name:AVILA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:AVILA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:8409 W CLEBURNE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123
Mailing Address - Country:US
Mailing Address - Phone:817-292-5927
Mailing Address - Fax:817-292-9595
Practice Address - Street 1:8409 W. CLEBURNE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123
Practice Address - Country:US
Practice Address - Phone:817-292-5927
Practice Address - Fax:817-292-9595
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX155511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice