Provider Demographics
NPI:1528232006
Name:EAST TEXAS CHILDREN'S DENTISTRY, P.A.
Entity Type:Organization
Organization Name:EAST TEXAS CHILDREN'S DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-577-9900
Mailing Address - Street 1:203 W 20TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-1101
Mailing Address - Country:US
Mailing Address - Phone:903-577-9900
Mailing Address - Fax:903-577-9901
Practice Address - Street 1:203 W 20TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-1101
Practice Address - Country:US
Practice Address - Phone:903-577-9900
Practice Address - Fax:903-577-9901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX104221223G0001X
TXTX 202141223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87D558OtherBCBS OF TEXAS
TX1387039OtherUNITED CONCORDIA