Provider Demographics
NPI: | 1437648110 |
---|---|
Name: | DENTISTS OF MIDLOTHIAN AND ORTHODONTICS PC |
Entity Type: | Organization |
Organization Name: | DENTISTS OF MIDLOTHIAN AND ORTHODONTICS PC |
Other - Org Name: | DENTISTS OF MIDLOTHIAN AND ORTHODONTICS |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JAYMI |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | STIVASON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 972-528-4802 |
Mailing Address - Street 1: | PO BOX 920050 |
Mailing Address - Street 2: | |
Mailing Address - City: | DALLAS |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75392-0050 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 714-845-8500 |
Mailing Address - Fax: | 303-952-0892 |
Practice Address - Street 1: | 2040 FM 663 STE 420 |
Practice Address - Street 2: | |
Practice Address - City: | MIDLOTHIAN |
Practice Address - State: | TX |
Practice Address - Zip Code: | 76065-6509 |
Practice Address - Country: | US |
Practice Address - Phone: | 972-528-4802 |
Practice Address - Fax: | 972-528-4802 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-05-08 |
Last Update Date: | 2022-02-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Multi-Specialty |