1790186930 NPI number — NAVASOTA DENTAL, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790186930 NPI number — NAVASOTA DENTAL, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NAVASOTA DENTAL, PC
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:
6
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:
1790186930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 NORTH LASALLE STREET
Provider Second Line Business Mailing Address:
SUITE 1A
Provider Business Mailing Address City Name:
NAVASOTA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77868
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:
415 NORTH LASALLE STREET
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
NAVASOTA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-799-5317
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/08/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RATH
Authorized Official First Name:
SUSHMITA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER / DENTIST
Authorized Official Telephone Number:
479-799-5317

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  29315 , 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)