Provider Demographics
NPI:1225435878
Name:RODEO DENTAL
Entity Type:Organization
Organization Name:RODEO DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:B
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:512-787-1977
Mailing Address - Street 1:PO BOX 4642
Mailing Address - Street 2:
Mailing Address - City:HORSESHOE BAY
Mailing Address - State:TX
Mailing Address - Zip Code:78657-4642
Mailing Address - Country:US
Mailing Address - Phone:512-787-1977
Mailing Address - Fax:830-596-7568
Practice Address - Street 1:2815 BAY WEST BLVD
Practice Address - Street 2:
Practice Address - City:HORSESHOE BAY
Practice Address - State:TX
Practice Address - Zip Code:78657
Practice Address - Country:US
Practice Address - Phone:512-787-1977
Practice Address - Fax:830-596-7568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX91921223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty