Provider Demographics
NPI:1043754740
Name:PREECE CHURCH AND ASSOCIATES, PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:PREECE CHURCH AND ASSOCIATES, PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:PREECE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-292-2004
Mailing Address - Street 1:5700 EDWARDS RANCH RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4127
Mailing Address - Country:US
Mailing Address - Phone:817-292-2004
Mailing Address - Fax:
Practice Address - Street 1:5700 EDWARDS RANCH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4127
Practice Address - Country:US
Practice Address - Phone:817-292-2004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX178281223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1407863806OtherNPI, TYPE 1
1881949592OtherNPI, TYPE 1
TX2168825-01Medicaid
TX0912362-03Medicaid
TX3608952-01Medicaid
TX1245251362OtherNPI, TYPE 1