Provider Demographics
NPI:1013208776
Name:SOY INTY PA
Entity Type:Organization
Organization Name:SOY INTY PA
Other - Org Name:NORTHEAST DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:915-751-7070
Mailing Address - Street 1:9201 DYER ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-6441
Mailing Address - Country:US
Mailing Address - Phone:915-751-7070
Mailing Address - Fax:
Practice Address - Street 1:9201 DYER ST
Practice Address - Street 2:SUITE B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-6441
Practice Address - Country:US
Practice Address - Phone:915-751-7070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24393261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1538314232OtherNPI TYPE 1