1952680837 NPI number — CRANIOFACIAL PAIN & SLEEP DENTISTRY, PA

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 1952680837 NPI number — CRANIOFACIAL PAIN & SLEEP DENTISTRY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRANIOFACIAL PAIN & SLEEP DENTISTRY, PA
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:
1952680837
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5032 CHAMPIONS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75901-7346
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-634-1333
Provider Business Mailing Address Fax Number:
936-634-1343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3516 PRESTON RD
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-8612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-985-4865
Provider Business Practice Location Address Fax Number:
972-985-7534
Provider Enumeration Date:
08/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BLEVINS
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
936-634-1333

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  7915 , 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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