Provider Demographics
NPI:1285021451
Name:ROCKWALL CROSSING ORTHODONTICS
Entity Type:Organization
Organization Name:ROCKWALL CROSSING ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-771-1117
Mailing Address - Street 1:711 S GOLIAD ST
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-3935
Mailing Address - Country:US
Mailing Address - Phone:972-771-1117
Mailing Address - Fax:
Practice Address - Street 1:711 S GOLIAD ST
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-3935
Practice Address - Country:US
Practice Address - Phone:972-771-1117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX199301223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty