Provider Demographics
NPI:1407863806
Name:CHURCH, AUSTIN RYAN (DDS)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:RYAN
Last Name:CHURCH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5700 EDWARDS RANCH RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4128
Mailing Address - Country:US
Mailing Address - Phone:817-292-2004
Mailing Address - Fax:817-292-7083
Practice Address - Street 1:1706 TREASURE HILLS BLVD
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8911
Practice Address - Country:US
Practice Address - Phone:956-365-6003
Practice Address - Fax:956-365-6780
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222411223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice