1689015505 NPI number — SOUTH TEXAS DENTAL ASSOCIATES, LP

Table of content: (NPI 1689015505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689015505 NPI number — SOUTH TEXAS DENTAL ASSOCIATES, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH TEXAS DENTAL ASSOCIATES, LP
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:
1689015505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6300 WEST LOOP S STE 650
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLAIRE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77401-2997
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-457-3445
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2482 JACKSBORO HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76114-2201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-626-4867
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/08/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEL
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER/PARTNER
Authorized Official Telephone Number:
713-457-3445

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  16570 , 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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