Provider Demographics
NPI:1417388398
Name:AY DENTAL PA
Entity Type:Organization
Organization Name:AY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:YOON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:979-233-1581
Mailing Address - Street 1:1723 N AVENUE K
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:77541-3605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1723 N AVENUE K
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:TX
Practice Address - Zip Code:77541-3605
Practice Address - Country:US
Practice Address - Phone:979-233-1581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty