Provider Demographics
NPI:1043746274
Name:ACE DENTAL05, PLLC
Entity Type:Organization
Organization Name:ACE DENTAL05, PLLC
Other - Org Name:ACE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:AC
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAKRAVARTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-925-0210
Mailing Address - Street 1:3108 S 31ST ST
Mailing Address - Street 2:3108
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-1803
Mailing Address - Country:US
Mailing Address - Phone:201-925-0210
Mailing Address - Fax:
Practice Address - Street 1:3108 S 31ST ST
Practice Address - Street 2:3108
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1803
Practice Address - Country:US
Practice Address - Phone:201-925-0210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-09
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty