Provider Demographics
NPI:1306227855
Name:A TOOTH FAIRY'S PLACE
Entity Type:Organization
Organization Name:A TOOTH FAIRY'S PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:OLIVAES-GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-541-3624
Mailing Address - Street 1:1725 CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-8328
Mailing Address - Country:US
Mailing Address - Phone:956-541-3624
Mailing Address - Fax:956-542-5998
Practice Address - Street 1:1725 CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-8328
Practice Address - Country:US
Practice Address - Phone:956-541-3624
Practice Address - Fax:956-542-5998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30954122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty