Provider Demographics
NPI:1114045267
Name:PACKARD ORTHODONTICS PA
Entity Type:Organization
Organization Name:PACKARD ORTHODONTICS PA
Other - Org Name:APPLE ORTHODONTIX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:972-578-7800
Mailing Address - Street 1:840 CENTRAL PKWY E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-5551
Mailing Address - Country:US
Mailing Address - Phone:972-578-7800
Mailing Address - Fax:972-867-9211
Practice Address - Street 1:840 CENTRAL PKWY E
Practice Address - Street 2:SUITE 100
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-5551
Practice Address - Country:US
Practice Address - Phone:972-578-7800
Practice Address - Fax:972-867-9211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX139301223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171851201Medicaid