Provider Demographics
NPI:1114453081
Name:DENTAL PROFESSIONALS OF TEXAS, P.A.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF TEXAS, P.A.
Other - Org Name:ENERGY SQUARE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:NICHOLE
Authorized Official - Last Name:TEUTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:4849 GREENVILLE AVE STE 173
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-4187
Mailing Address - Country:US
Mailing Address - Phone:217-540-8972
Mailing Address - Fax:
Practice Address - Street 1:4849 GREENVILLE AVE STE 173
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-4187
Practice Address - Country:US
Practice Address - Phone:214-369-9966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL HEALTH ASSOCIATES OF TEXAS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-11
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty