Provider Demographics
NPI:1497945679
Name:GUZMAN, SERGIO IVAN (DDS)
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:IVAN
Last Name:GUZMAN
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 1:1317 ST CLAIRE BLVD STE A3
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-6636
Mailing Address - Country:US
Mailing Address - Phone:956-581-4403
Mailing Address - Fax:956-581-2242
Practice Address - Street 1:1317 ST CLAIRE BLVD STE A3
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-6636
Practice Address - Country:US
Practice Address - Phone:956-581-4403
Practice Address - Fax:956-581-2242
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2008-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226441223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX186204704Medicaid
TX22644OtherTSBDE
TX186204705Medicaid
TXB22644-01OtherCHIPS
TXK0152252OtherDPS