Provider Demographics
NPI:1144384785
Name:THE TOOTH PLACE, P.A.
Entity Type:Organization
Organization Name:THE TOOTH PLACE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-542-9200
Mailing Address - Street 1:2501 PAREDES LINE RD STE B3
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-1195
Mailing Address - Country:US
Mailing Address - Phone:956-542-9200
Mailing Address - Fax:956-542-9913
Practice Address - Street 1:2501 PAREDES LINE RD STE B3
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-1195
Practice Address - Country:US
Practice Address - Phone:956-542-9200
Practice Address - Fax:956-542-9913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX206131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151128901Medicaid
TX151128902Medicaid
TXB20613-1OtherTX CHIPS GROUP NUMBER
TX172064101Medicaid
TX=========Medicaid