Provider Demographics
NPI:1629447495
Name:UTHHSC-PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:UTHHSC-PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BADGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:713-486-4141
Mailing Address - Street 1:7500 CAMBRIDGE ST
Mailing Address - Street 2:SUITE 5301
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2032
Mailing Address - Country:US
Mailing Address - Phone:713-486-4141
Mailing Address - Fax:713-486-4179
Practice Address - Street 1:7500 CAMBRIDGE ST
Practice Address - Street 2:SUITE 5301
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2032
Practice Address - Country:US
Practice Address - Phone:713-486-4141
Practice Address - Fax:713-486-4179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009733901Medicaid