Provider Demographics
NPI:1467757112
Name:MIDLAND PARK MALL DENTAL PRACTICE, P.C.
Entity Type:Organization
Organization Name:MIDLAND PARK MALL DENTAL PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-520-4867
Mailing Address - Street 1:4511 N MIDKIFF RD STE E15
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-3242
Mailing Address - Country:US
Mailing Address - Phone:432-520-4867
Mailing Address - Fax:432-694-7927
Practice Address - Street 1:4511 N MIDKIFF RD STE E15
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-3242
Practice Address - Country:US
Practice Address - Phone:432-520-4867
Practice Address - Fax:432-694-7927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty