Provider Demographics
NPI:1598846180
Name:PENDERGRASS WILKIE DENTISTRY PARTNERSHIP
Entity Type:Organization
Organization Name:PENDERGRASS WILKIE DENTISTRY PARTNERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PENDERGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PA
Authorized Official - Phone:806-358-8801
Mailing Address - Street 1:6020 BELPREE ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-3333
Mailing Address - Country:US
Mailing Address - Phone:806-358-8801
Mailing Address - Fax:806-358-8894
Practice Address - Street 1:6020 BELPREE ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-3333
Practice Address - Country:US
Practice Address - Phone:806-358-8802
Practice Address - Fax:806-358-8894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX197251223G0001X
TX208791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty