Provider Demographics
NPI:1477871259
Name:SAINT APOLONIA MEDICAID DENTAL CLINIC NO 2 OF TEXAS PA
Entity Type:Organization
Organization Name:SAINT APOLONIA MEDICAID DENTAL CLINIC NO 2 OF TEXAS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:D D S
Authorized Official - Phone:979-733-8844
Mailing Address - Street 1:106 SHULT DR
Mailing Address - Street 2:SUITE A/B
Mailing Address - City:COLUMBUS
Mailing Address - State:TX
Mailing Address - Zip Code:78934-3016
Mailing Address - Country:US
Mailing Address - Phone:979-733-8844
Mailing Address - Fax:979-733-8848
Practice Address - Street 1:106 SHULT DR
Practice Address - Street 2:SUITE A/B
Practice Address - City:COLUMBUS
Practice Address - State:TX
Practice Address - Zip Code:78934-3016
Practice Address - Country:US
Practice Address - Phone:979-733-8844
Practice Address - Fax:979-733-8848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty