Provider Demographics
NPI:1407078892
Name:AGGIELAND DENTAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:AGGIELAND DENTAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:ROXANE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MLCAK-SPENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-696-4511
Mailing Address - Street 1:2700 EARL RUDDER FRWY S
Mailing Address - Street 2:SUITE 1900
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-5032
Mailing Address - Country:US
Mailing Address - Phone:979-696-4511
Mailing Address - Fax:
Practice Address - Street 1:2700 EARL RUDDER FRWY S
Practice Address - Street 2:SUITE 1900
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-5032
Practice Address - Country:US
Practice Address - Phone:979-696-4511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX157451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82D692OtherBCBS PROVIDER #