1093038333 NPI number — NAVARRO ORTHODONTICS OF FORTWORTH,

Table of content: (NPI 1093038333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093038333 NPI number — NAVARRO ORTHODONTICS OF FORTWORTH,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NAVARRO ORTHODONTICS OF FORTWORTH,
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:
1093038333
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4514 COLE AVE STE 910
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-526-3363
Provider Business Mailing Address Fax Number:
214-520-7753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
233 NE 28TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORTWORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76164-7205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-710-2480
Provider Business Practice Location Address Fax Number:
817-710-2487
Provider Enumeration Date:
03/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
NAVARRO
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-526-3363

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 210610601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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