Provider Demographics
NPI:1497048029
Name:STOCKDALE DENTAL EXCELLENCE
Entity Type:Organization
Organization Name:STOCKDALE DENTAL EXCELLENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:830-996-3635
Mailing Address - Street 1:3567 STATE HIGHWAY 123 N
Mailing Address - Street 2:
Mailing Address - City:STOCKDALE
Mailing Address - State:TX
Mailing Address - Zip Code:78160-6244
Mailing Address - Country:US
Mailing Address - Phone:830-996-3635
Mailing Address - Fax:830-996-3696
Practice Address - Street 1:3567 STATE HIGHWAY 123 N
Practice Address - Street 2:
Practice Address - City:STOCKDALE
Practice Address - State:TX
Practice Address - Zip Code:78160-6244
Practice Address - Country:US
Practice Address - Phone:830-996-3635
Practice Address - Fax:830-996-3696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21531122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165753801Medicaid
TX1982752622OtherNPI (INDIVIDUAL)