1093196644 NPI number — NORTHWEST DENTAL ASSOCIATES P.A.

Table of content: JENAI MATILDE ROJO MD (NPI 1225823396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093196644 NPI number — NORTHWEST DENTAL ASSOCIATES P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST DENTAL ASSOCIATES P.A.
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:
1093196644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11066 PECAN PARK BLVD.
Provider Second Line Business Mailing Address:
SUITE #411
Provider Business Mailing Address City Name:
CEDAR PARK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-219-7484
Provider Business Mailing Address Fax Number:
512-219-6505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11066 PECAN PARK BLVD.
Provider Second Line Business Practice Location Address:
SUITE #411
Provider Business Practice Location Address City Name:
CEDAR PARK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-219-7484
Provider Business Practice Location Address Fax Number:
512-219-6505
Provider Enumeration Date:
06/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PHAM
Authorized Official First Name:
TOAI
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
DOCTOR/OWNER
Authorized Official Telephone Number:
512-219-7484

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  18096 , 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)





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