Provider Demographics
NPI:1255492815
Name:DENTAL HEALTH ASSOCIATES OF TEXAS, PC
Entity Type:Organization
Organization Name:DENTAL HEALTH ASSOCIATES OF TEXAS, PC
Other - Org Name:COPPERFIELD CROSSING DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:15620 FM 529 ROAD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095
Mailing Address - Country:US
Mailing Address - Phone:281-855-7774
Mailing Address - Fax:281-855-7785
Practice Address - Street 1:15620 FM 529 ROAD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095
Practice Address - Country:US
Practice Address - Phone:281-855-7774
Practice Address - Fax:281-855-7785
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL HEALTH ASSOCIATES OF TEXAS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-13
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX129611223G0001X
TX135091223G0001X
TX132451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty