Provider Demographics
NPI: | 1497488373 |
---|---|
Name: | TEXAS DENTAL ORTHODONTICS PRACTICE, PLLC |
Entity Type: | Organization |
Organization Name: | TEXAS DENTAL ORTHODONTICS PRACTICE, PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DATA ANALYST |
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: | 20540 STATE HIGHWAY 46 W STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | SPRING BRANCH |
Practice Address - State: | TX |
Practice Address - Zip Code: | 78070-6825 |
Practice Address - Country: | US |
Practice Address - Phone: | 830-980-8099 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | TEXAS DENTAL ORTHODONTICS PRACTICE, PLLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2022-07-07 |
Last Update Date: | 2022-07-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Multi-Specialty |