1710011259 NPI number — AIRLINE DENTAL CLINIC

Table of content: (NPI 1710011259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710011259 NPI number — AIRLINE DENTAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AIRLINE DENTAL CLINIC
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:
1710011259
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1257 ARCHLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77055-6706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-464-3326
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5990 AIRLINE DR
Provider Second Line Business Practice Location Address:
SUITE 180
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77076-4233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-694-8333
Provider Business Practice Location Address Fax Number:
713-694-8362
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CAMPA
Authorized Official First Name:
IRASEMA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE ASSISTANT
Authorized Official Telephone Number:
713-697-2631

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  22558 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 16842 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 169622101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 177617101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009806301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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