Provider Demographics
NPI:1477213312
Name:TEXAS DENTAL SPECIALIST PRACTICE, PLLC
Entity Type:Organization
Organization Name:TEXAS DENTAL SPECIALIST PRACTICE, PLLC
Other - Org Name:TEXAS DENTAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTELAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-372-5605
Mailing Address - Street 1:6110 BARNES RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-3748
Practice Address - Country:US
Practice Address - Phone:830-379-9310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEXAS DENTAL SPECIALIST PRACTICE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-12-20
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty