Provider Demographics
NPI:1558437228
Name:ACADEMY DENTAL CENTER
Entity Type:Organization
Organization Name:ACADEMY DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:KNOTT
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:254-982-4750
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER ACADEMY
Mailing Address - State:TX
Mailing Address - Zip Code:76554-0546
Mailing Address - Country:US
Mailing Address - Phone:254-982-4750
Mailing Address - Fax:254-982-4721
Practice Address - Street 1:709 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER ACADEMY
Practice Address - State:TX
Practice Address - Zip Code:76554-2605
Practice Address - Country:US
Practice Address - Phone:254-982-4750
Practice Address - Fax:254-982-4721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14945122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0904500-02Medicaid