Provider Demographics
NPI:1508958117
Name:KILLEEN FAMILY DENTISTRY
Entity Type:Organization
Organization Name:KILLEEN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:YASSA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:254-699-6799
Mailing Address - Street 1:3300 E CENTRAL TEXAS EXPY
Mailing Address - Street 2:SUITE #302
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-5306
Mailing Address - Country:US
Mailing Address - Phone:254-699-6799
Mailing Address - Fax:254-699-3465
Practice Address - Street 1:3300 E CENTRAL TEXAS EXPY
Practice Address - Street 2:SUITE #302
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5306
Practice Address - Country:US
Practice Address - Phone:254-699-6799
Practice Address - Fax:254-699-3465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG60488-1OtherTEXAS CHIP
TX172223301Medicaid