1265898977 NPI number — OZA DENTAL PLLC

Table of content: DR. CLINTON WAYNE SERAFINO PT, DPT (NPI 1497159917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265898977 NPI number — OZA DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OZA DENTAL PLLC
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:
1265898977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 TOWNE CROSSING BLVD
Provider Second Line Business Mailing Address:
APT 1213
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063-8905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-744-0760
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1561 SW WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
SUITE 435
Provider Business Practice Location Address City Name:
BURLESON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76028-8719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-744-0760
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
OZA
Authorized Official First Name:
JAY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
201-744-0760

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  30486 , 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: 340662101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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