Provider Demographics
NPI:1316039910
Name:VALLEY DENTAL PA
Entity Type:Organization
Organization Name:VALLEY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-546-2973
Mailing Address - Street 1:2334 BOCA CHICA BLVD
Mailing Address - Street 2:SUITE #200
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-2230
Mailing Address - Country:US
Mailing Address - Phone:956-546-2973
Mailing Address - Fax:956-546-1342
Practice Address - Street 1:2334 BOCA CHICA BLVD
Practice Address - Street 2:SUITE #200
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-2230
Practice Address - Country:US
Practice Address - Phone:956-546-2973
Practice Address - Fax:956-546-1342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162986701Medicaid
TXG60109-6OtherTEXAS CHIP PROVIDER NUMBE