Provider Demographics
NPI:1053637199
Name:ST. JUDE DENTAL P.C
Entity Type:Organization
Organization Name:ST. JUDE DENTAL P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:EMEKA
Authorized Official - Middle Name:JUDE
Authorized Official - Last Name:ABAZIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-224-5397
Mailing Address - Street 1:1001 N BECKLEY AVE #420C
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115
Mailing Address - Country:US
Mailing Address - Phone:972-224-5397
Mailing Address - Fax:972-224-0344
Practice Address - Street 1:8420 S SAM HOUSTON PKWY W STE 260
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77085-2283
Practice Address - Country:US
Practice Address - Phone:972-224-5397
Practice Address - Fax:972-224-0344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22568261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1578657763Medicaid