Provider Demographics
NPI:1225675366
Name:ACRE WOOD DENTAL - GATESVILLE PA
Entity Type:Organization
Organization Name:ACRE WOOD DENTAL - GATESVILLE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KISHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-778-4951
Mailing Address - Street 1:105 N LUTTERLOH AVE
Mailing Address - Street 2:
Mailing Address - City:GATESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76528-1421
Mailing Address - Country:US
Mailing Address - Phone:254-865-7918
Mailing Address - Fax:254-248-0529
Practice Address - Street 1:105 N LUTTERLOH AVE
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76528-1421
Practice Address - Country:US
Practice Address - Phone:254-865-7918
Practice Address - Fax:254-248-0529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty