Provider Demographics
NPI:1063982940
Name:NUSTAR ORTHODONTICS, PLLC
Entity type:Organization
Organization Name:NUSTAR ORTHODONTICS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-274-7071
Mailing Address - Street 1:3201 CHERRY RIDGE ST STE A101
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-4824
Mailing Address - Country:US
Mailing Address - Phone:210-962-6421
Mailing Address - Fax:210-340-0446
Practice Address - Street 1:7878 GATEWAY BLVD E STE 300
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79915-1802
Practice Address - Country:US
Practice Address - Phone:210-962-6421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-04
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty