1942525209 NPI number — GALVESTON DENTAL PC

Table of content: (NPI 1942525209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942525209 NPI number — GALVESTON DENTAL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GALVESTON DENTAL PC
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:
AFFORDABLE DENTAL GALVESTON
Provider Other Organization Name Type Code:
3
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:
1942525209
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5934 BROADWAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALVESTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77551-4305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-740-7744
Provider Business Mailing Address Fax Number:
409-744-4541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5934 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALVESTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77551-4305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-740-7744
Provider Business Practice Location Address Fax Number:
409-744-4541
Provider Enumeration Date:
03/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
OSAMOR
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
409-740-0171

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  21886 , 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: 210631201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com