Provider Demographics
NPI:1023676855
Name:TREVINO DE LASCURAIN, SERGIO MAURICIO (DDS)
Entity type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:MAURICIO
Last Name:TREVINO DE LASCURAIN
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 1:2940 MALLORY CIR
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-1818
Mailing Address - Country:US
Mailing Address - Phone:407-566-2222
Mailing Address - Fax:
Practice Address - Street 1:2940 MALLORY CIR
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747
Practice Address - Country:US
Practice Address - Phone:407-566-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN241661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice