Provider Demographics
NPI:1467689307
Name:ST PAUL CHILDREN'S MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ST PAUL CHILDREN'S MEDICAL CORPORATION
Other - Org Name:ST PAUL DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-531-9455
Mailing Address - Street 1:132 S HORACE AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-6159
Mailing Address - Country:US
Mailing Address - Phone:903-593-7607
Mailing Address - Fax:903-593-3965
Practice Address - Street 1:132 S HORACE AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-6159
Practice Address - Country:US
Practice Address - Phone:903-593-7607
Practice Address - Fax:903-593-3965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203763201Medicaid
TXG6063601OtherDELTA DENTAL- CHIPS
TX203763202OtherMEDICAID-CSCHN