Provider Demographics
NPI:1518421437
Name:WEST TEXAS PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:WEST TEXAS PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ARCHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS; MPH
Authorized Official - Phone:432-242-5747
Mailing Address - Street 1:3306 ANDREWS HWY
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79703-5131
Mailing Address - Country:US
Mailing Address - Phone:432-242-5747
Mailing Address - Fax:
Practice Address - Street 1:3306 ANDREWS HWY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-5131
Practice Address - Country:US
Practice Address - Phone:432-242-5747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202112312Medicaid