Provider Demographics
NPI:1306391362
Name:ALPHA OMEGA DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:ALPHA OMEGA DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LASSITER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:254-666-1366
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:HEWITT
Mailing Address - State:TX
Mailing Address - Zip Code:76643-0428
Mailing Address - Country:US
Mailing Address - Phone:254-666-1366
Mailing Address - Fax:254-666-4766
Practice Address - Street 1:211 SUN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:HEWITT
Practice Address - State:TX
Practice Address - Zip Code:76643-3571
Practice Address - Country:US
Practice Address - Phone:254-666-1366
Practice Address - Fax:254-666-4766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15519305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization