Provider Demographics
NPI:1619327228
Name:ELEGANZ DENTISTRY, PC
Entity Type:Organization
Organization Name:ELEGANZ DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:QUINCY
Authorized Official - Middle Name:
Authorized Official - Last Name:ATTIPOE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:469-231-4419
Mailing Address - Street 1:1618 N VETERANS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1618 N VETERANS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-3216
Practice Address - Country:US
Practice Address - Phone:469-231-4419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2Medicaid