Provider Demographics
NPI:1275821647
Name:CELEBRITY DENTAL PC
Entity Type:Organization
Organization Name:CELEBRITY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:ELBA
Authorized Official - Last Name:GARCIA-IBANCOVICHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-388-4808
Mailing Address - Street 1:4808 S BUCKNER BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227-2348
Mailing Address - Country:US
Mailing Address - Phone:214-388-4808
Mailing Address - Fax:214-388-4100
Practice Address - Street 1:4808 S BUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-2348
Practice Address - Country:US
Practice Address - Phone:214-388-4808
Practice Address - Fax:214-388-4100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16354122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16354Medicaid