Provider Demographics
NPI:1073832291
Name:EAGLE DENTAL P.C.
Entity Type:Organization
Organization Name:EAGLE DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:ODIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:832-790-2223
Mailing Address - Street 1:12609 S. GESSNER DRIVE
Mailing Address - Street 2:STE. F
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77071-2803
Mailing Address - Country:US
Mailing Address - Phone:713-774-6700
Mailing Address - Fax:713-774-6704
Practice Address - Street 1:12609 S GESSNER DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77071-2803
Practice Address - Country:US
Practice Address - Phone:713-774-6700
Practice Address - Fax:713-774-6704
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUN DENTAL GROUP P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-27
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190960801Medicaid
B22575-01OtherCHIP
TX214288701Medicaid
B22575-02OtherCHIP