Provider Demographics
NPI:1528194099
Name:NORTHLINE DENTAL CENTER
Entity Type:Organization
Organization Name:NORTHLINE DENTAL CENTER
Other - Org Name:NONE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:713-691-1831
Mailing Address - Street 1:4402 AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77022-2934
Mailing Address - Country:US
Mailing Address - Phone:713-691-1831
Mailing Address - Fax:
Practice Address - Street 1:4402 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77022-2934
Practice Address - Country:US
Practice Address - Phone:713-691-1831
Practice Address - Fax:713-691-3836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty