1407521180 NPI number — DENTRUST DENTAL TEXAS, P.C.

Table of content: (NPI 1407521180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407521180 NPI number — DENTRUST DENTAL TEXAS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTRUST DENTAL TEXAS, 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:
1407521180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1221 VINEWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEFFNER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33584-4829
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-451-4503
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4250 CLEAR CREEK RD
Provider Second Line Business Practice Location Address:
#213
Provider Business Practice Location Address City Name:
FT. HOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-423-9234
Provider Business Practice Location Address Fax Number:
254-312-7441
Provider Enumeration Date:
08/13/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
DIRECTOR OF CREDENTIALING
Authorized Official Telephone Number:
267-927-5000

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: 18598 . This is a "LC LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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