Provider Demographics
NPI:1083263149
Name:RECONSTRUCTIVE DENTAL SPECIALISTS OF TEXAS
Entity Type:Organization
Organization Name:RECONSTRUCTIVE DENTAL SPECIALISTS OF TEXAS
Other - Org Name:GREAT LIFE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FAWZI
Authorized Official - Middle Name:
Authorized Official - Last Name:HIJAZI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-821-5316
Mailing Address - Street 1:235 E HILDEBRAND AVE # 200
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2430
Mailing Address - Country:US
Mailing Address - Phone:210-821-5316
Mailing Address - Fax:210-829-4686
Practice Address - Street 1:235 E HILDEBRAND AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2430
Practice Address - Country:US
Practice Address - Phone:210-821-5316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-10
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty