Provider Demographics
NPI:1124372016
Name:SYNERGY DENTAL, LLC
Entity Type:Organization
Organization Name:SYNERGY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PURAVKUMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-895-9021
Mailing Address - Street 1:4401 RIVER VALLEY DR
Mailing Address - Street 2:APT. 605
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-5250
Mailing Address - Country:US
Mailing Address - Phone:201-895-9021
Mailing Address - Fax:361-767-8802
Practice Address - Street 1:109 E AVENUE J
Practice Address - Street 2:
Practice Address - City:ROBSTOWN
Practice Address - State:TX
Practice Address - Zip Code:78380-2347
Practice Address - Country:US
Practice Address - Phone:361-387-1531
Practice Address - Fax:361-767-8802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24395122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty