Provider Demographics
NPI:1417260001
Name:ELITE DENTAL ASSOCIATES - FIREWHEEL, PC
Entity Type:Organization
Organization Name:ELITE DENTAL ASSOCIATES - FIREWHEEL, PC
Other - Org Name:WATERMARK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:214-220-2424
Mailing Address - Street 1:5435 N GARLAND AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040-2723
Mailing Address - Country:US
Mailing Address - Phone:972-530-7374
Mailing Address - Fax:214-452-8203
Practice Address - Street 1:5435 N GARLAND AVE STE 125
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-2723
Practice Address - Country:US
Practice Address - Phone:972-530-7374
Practice Address - Fax:214-452-8203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX189941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty