Provider Demographics
NPI:1407277239
Name:NORTHEAST TEXAS COMMUNITY COLLEGE DENTAL HYGIENE CLINIC
Entity Type:Organization
Organization Name:NORTHEAST TEXAS COMMUNITY COLLEGE DENTAL HYGIENE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:JO
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RDH, PHD
Authorized Official - Phone:903-434-8352
Mailing Address - Street 1:PO BOX 1307
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75456-9991
Mailing Address - Country:US
Mailing Address - Phone:903-434-8350
Mailing Address - Fax:903-434-4424
Practice Address - Street 1:2886 FM 1735, CHAPEL HILL ROAD
Practice Address - Street 2:
Practice Address - City:MT. PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455
Practice Address - Country:US
Practice Address - Phone:903-434-8350
Practice Address - Fax:903-434-4424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty