1790928604 NPI number — PERIODONTICS & IMPLANT CENTER OF MCKINNEY

Table of content: (NPI 1790928604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790928604 NPI number — PERIODONTICS & IMPLANT CENTER OF MCKINNEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERIODONTICS & IMPLANT CENTER OF MCKINNEY
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:
1790928604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
321 N CENTRAL EXPY
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
MCKINNEY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75070-3519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-540-5700
Provider Business Mailing Address Fax Number:
214-544-8700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
321 N CENTRAL EXPY
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MCKINNEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75070-3519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-540-5700
Provider Business Practice Location Address Fax Number:
214-544-8700
Provider Enumeration Date:
04/08/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHANG
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
972-540-5700

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  23754 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0300X , with the licence number: 23754 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0700X , with the licence number: 23754 , 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)