Provider Demographics
NPI:1205375037
Name:FRONTERA HEALTHCARE NETWORK
Entity Type:Organization
Organization Name:FRONTERA HEALTHCARE NETWORK
Other - Org Name:FRONTERA HEALTHCARE NETWORK - EDEN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:KLEIBRINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-869-5500
Mailing Address - Street 1:604 EAKER
Mailing Address - Street 2:PO BOX 989
Mailing Address - City:EDEN
Mailing Address - State:TX
Mailing Address - Zip Code:76837-0989
Mailing Address - Country:US
Mailing Address - Phone:325-869-5500
Mailing Address - Fax:325-869-5692
Practice Address - Street 1:212 JACKSON STREET
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:TX
Practice Address - Zip Code:76837-0246
Practice Address - Country:US
Practice Address - Phone:325-869-8471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
TX3016124Q00000X
TX75306126800000X
TX15190126800000X
TX63147126800000X
TX14944122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty