1073832291 NPI number — EAGLE DENTAL P.C.

Table of content: (NPI 1073832291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073832291 NPI number — EAGLE DENTAL P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE DENTAL P.C.
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:
1073832291
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12609 S. GESSNER DRIVE
Provider Second Line Business Mailing Address:
STE. F
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77071-2803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-774-6700
Provider Business Mailing Address Fax Number:
713-774-6704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12609 S GESSNER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77071-2803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-774-6700
Provider Business Practice Location Address Fax Number:
713-774-6704
Provider Enumeration Date:
05/27/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ODIA
Authorized Official First Name:
DAVIN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
832-790-2223

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  22575 , 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: 190960801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: B22575-01 . This is a "CHIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 214288701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: B22575-02 . This is a "CHIP" identifier . This identifiers is of the category "OTHER".