Provider Demographics
NPI:1205019478
Name:GALENA PARK DENTAL
Entity Type:Organization
Organization Name:GALENA PARK DENTAL
Other - Org Name:GALENA PARK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:N
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-672-4779
Mailing Address - Street 1:1705 CLINTON DR
Mailing Address - Street 2:
Mailing Address - City:GALENA PARK
Mailing Address - State:TX
Mailing Address - Zip Code:77547-3224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 CLINTON DR
Practice Address - Street 2:
Practice Address - City:GALENA PARK
Practice Address - State:TX
Practice Address - Zip Code:77547-3224
Practice Address - Country:US
Practice Address - Phone:713-672-4479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22483122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178688101Medicaid