1053656686 NPI number — WELLNESS DENTAL,P.C.

Table of content: (NPI 1053656686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053656686 NPI number — WELLNESS DENTAL,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLNESS 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:
1053656686
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9828 GREAT HILLS TRL
Provider Second Line Business Mailing Address:
#305
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78759-6391
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
521-535-5257
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9828 GREAT HILLS TRL
Provider Second Line Business Practice Location Address:
#305
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78759-6391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
521-535-5257
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GIPLE-JOHNSON
Authorized Official First Name:
FRANCISCA
Authorized Official Middle Name:
GBIE
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
512-535-5257

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  24200 , 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: 191265102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com