Provider Demographics
NPI:1235779109
Name:CHILDREN'S DENTAL DEPOT PA
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL DEPOT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AND INSURANCE COORD
Authorized Official - Prefix:
Authorized Official - First Name:JOLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PLAGENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-855-2337
Mailing Address - Street 1:11165 LA QUINTA PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-5221
Mailing Address - Country:US
Mailing Address - Phone:915-855-2337
Mailing Address - Fax:915-503-1012
Practice Address - Street 1:833 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-5312
Practice Address - Country:US
Practice Address - Phone:903-686-9992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty