Provider Demographics
NPI:1558363036
Name:FAWCETT CENTER FOR DENTISTRY, PA
Entity Type:Organization
Organization Name:FAWCETT CENTER FOR DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYDE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-440-6648
Mailing Address - Street 1:13956 CUTTEN RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77069-2215
Mailing Address - Country:US
Mailing Address - Phone:281-440-6648
Mailing Address - Fax:281-440-4120
Practice Address - Street 1:13956 CUTTEN RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77069-2215
Practice Address - Country:US
Practice Address - Phone:281-440-6648
Practice Address - Fax:281-440-4120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-13
Last Update Date:2008-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX143011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty