Provider Demographics
NPI:1922838614
Name:MORALES VILLARREAL, LUIS ANGEL (DMD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ANGEL
Last Name:MORALES VILLARREAL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:852 N PERSHING ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT ANGEL
Mailing Address - State:OR
Mailing Address - Zip Code:97362-9558
Mailing Address - Country:US
Mailing Address - Phone:503-991-2102
Mailing Address - Fax:
Practice Address - Street 1:1289 WINCHESTER AVE
Practice Address - Street 2:
Practice Address - City:REEDSPORT
Practice Address - State:OR
Practice Address - Zip Code:97467-1373
Practice Address - Country:US
Practice Address - Phone:541-707-6027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD120561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice