1275687212 NPI number — PACIFIC DENTAL CARE TUAN DI SU DDS PA

Table of content: (NPI 1275687212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275687212 NPI number — PACIFIC DENTAL CARE TUAN DI SU DDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC DENTAL CARE TUAN DI SU DDS PA
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:
1275687212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3043 OLD DENTON RD
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
CARROLLTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75007-5036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3043 OLD DENTON RD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75007-5036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-492-5838
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SU
Authorized Official First Name:
TUAN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DDS
Authorized Official Telephone Number:
972-567-7450

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 144548802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 149824801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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