Provider Demographics
NPI:1073614772
Name:AMARILLO PEDIATRIC DENTISTRY AND ORTHODONTICS, PA
Entity Type:Organization
Organization Name:AMARILLO PEDIATRIC DENTISTRY AND ORTHODONTICS, PA
Other - Org Name:AMARILLO PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:806-350-5437
Mailing Address - Street 1:2455 W INTERSTATE 40
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-1852
Mailing Address - Country:US
Mailing Address - Phone:806-350-5437
Mailing Address - Fax:806-350-5438
Practice Address - Street 1:2455 W INTERSTATE 40
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-1852
Practice Address - Country:US
Practice Address - Phone:806-350-5437
Practice Address - Fax:806-350-5438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX186611223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0042NQOtherBLUE CROSS BLUE SHIELD
TX177133901Medicaid
TXU66092Medicare UPIN