1750567434 NPI number — LAS PALMAS CHILDREN'S DENTISTRY

Table of content: (NPI 1750567434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750567434 NPI number — LAS PALMAS CHILDREN'S DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAS PALMAS CHILDREN'S DENTISTRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750567434
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7013 SOUTH CAGE BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
PHARR
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-787-3333
Provider Business Mailing Address Fax Number:
956-787-7333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7013 SOUTH CAGE BLVD.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PHARR
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-787-3333
Provider Business Practice Location Address Fax Number:
956-787-7333
Provider Enumeration Date:
01/13/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
MARIA DEJESUS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/PEDIATRIC DENTIST
Authorized Official Telephone Number:
956-787-3333

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  14305 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 20393 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 190342901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".