Provider Demographics
NPI:1275812430
Name:ADVANCED IMPLANT AND PERIODONTAL PROFESSIONALS PA
Entity Type:Organization
Organization Name:ADVANCED IMPLANT AND PERIODONTAL PROFESSIONALS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:D
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:281-681-2422
Mailing Address - Street 1:1011 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE #140
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3249
Mailing Address - Country:US
Mailing Address - Phone:281-681-2422
Mailing Address - Fax:866-352-0357
Practice Address - Street 1:1011 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE #140
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3249
Practice Address - Country:US
Practice Address - Phone:281-681-2422
Practice Address - Fax:866-352-0357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211111223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty