Provider Demographics
NPI:1093262172
Name:ACCESS DENTAL OF FREDERICKSBURG PA
Entity Type:Organization
Organization Name:ACCESS DENTAL OF FREDERICKSBURG PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIEN
Authorized Official - Middle Name:DINH
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-514-1672
Mailing Address - Street 1:1200 W WALNUT HILL LN
Mailing Address - Street 2:3950
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3029
Mailing Address - Country:US
Mailing Address - Phone:972-514-1672
Mailing Address - Fax:
Practice Address - Street 1:4315 FREDERICKSBURG BALCONES HEIGHT
Practice Address - Street 2:100A
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201
Practice Address - Country:US
Practice Address - Phone:972-514-1672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty