Provider Demographics
NPI:1508021114
Name:CRESTWAY PARK DENTAL, P.A.
Entity Type:Organization
Organization Name:CRESTWAY PARK DENTAL, P.A.
Other - Org Name:ALLEN FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-675-3811
Mailing Address - Street 1:208 CRESTWAY ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751
Mailing Address - Country:US
Mailing Address - Phone:903-675-3811
Mailing Address - Fax:903-675-2800
Practice Address - Street 1:208 CRESTWAY ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751
Practice Address - Country:US
Practice Address - Phone:903-675-3811
Practice Address - Fax:903-675-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty