Provider Demographics
NPI:1083970792
Name:FAMILY TREE DENTAL GROUP ONE PLLC
Entity Type:Organization
Organization Name:FAMILY TREE DENTAL GROUP ONE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:AZUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-310-5999
Mailing Address - Street 1:200 N RED BUD LN
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-8904
Mailing Address - Country:US
Mailing Address - Phone:512-310-5999
Mailing Address - Fax:512-341-9950
Practice Address - Street 1:200 N RED BUD LN
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-8904
Practice Address - Country:US
Practice Address - Phone:512-310-5999
Practice Address - Fax:512-341-9950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty