Provider Demographics
NPI:1003322678
Name:UNITED SMILE CENTER PA
Entity Type:Organization
Organization Name:UNITED SMILE CENTER PA
Other - Org Name:CELINA FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-779-4404
Mailing Address - Street 1:3248 S PRESTON RD STE 140
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:TX
Mailing Address - Zip Code:75009-3899
Mailing Address - Country:US
Mailing Address - Phone:214-851-0130
Mailing Address - Fax:214-851-0111
Practice Address - Street 1:3248 S PRESTON RD STE 140
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:TX
Practice Address - Zip Code:75009-3899
Practice Address - Country:US
Practice Address - Phone:214-851-0130
Practice Address - Fax:214-851-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23268122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX23268Other1972795532
TX23268OtherLICENSE