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?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty