Provider Demographics
NPI:1083750285
Name:WASHINGTON DENTAL
Entity Type:Organization
Organization Name:WASHINGTON DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAURICIO
Authorized Official - Middle Name:
Authorized Official - Last Name:TOVAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:713-802-0044
Mailing Address - Street 1:2515 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-6342
Mailing Address - Country:US
Mailing Address - Phone:713-802-0044
Mailing Address - Fax:713-802-2162
Practice Address - Street 1:2515 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007-6342
Practice Address - Country:US
Practice Address - Phone:713-802-0044
Practice Address - Fax:713-802-2162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX170001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX090792502Medicaid
TX160126201Medicaid