Provider Demographics
NPI:1275938425
Name:EDGE-MD DENTACARE, PLLC
Entity Type:Organization
Organization Name:EDGE-MD DENTACARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-532-2000
Mailing Address - Street 1:2022 REGIONAL MEDICAL DR
Mailing Address - Street 2:SUITE 1315
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-7231
Mailing Address - Country:US
Mailing Address - Phone:979-532-2000
Mailing Address - Fax:979-532-2008
Practice Address - Street 1:2440 S COLLINS ST
Practice Address - Street 2:SUITE 140
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-1239
Practice Address - Country:US
Practice Address - Phone:817-459-2501
Practice Address - Fax:817-459-2341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0318207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty