Provider Demographics
NPI:1053656686
Name:WELLNESS DENTAL,P.C.
Entity Type:Organization
Organization Name:WELLNESS DENTAL,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANCISCA
Authorized Official - Middle Name:GBIE
Authorized Official - Last Name:GIPLE-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-535-5257
Mailing Address - Street 1:9828 GREAT HILLS TRL
Mailing Address - Street 2:#305
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-6391
Mailing Address - Country:US
Mailing Address - Phone:521-535-5257
Mailing Address - Fax:
Practice Address - Street 1:9828 GREAT HILLS TRL
Practice Address - Street 2:#305
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-6391
Practice Address - Country:US
Practice Address - Phone:521-535-5257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-08
Last Update Date:2012-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191265102Medicaid