Provider Demographics
NPI:1629663356
Name:EL PASO PELLICANO FAMILY DENTISTRY
Entity Type:Organization
Organization Name:EL PASO PELLICANO FAMILY DENTISTRY
Other - Org Name:PELLICANO FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASVINDER
Authorized Official - Middle Name:S
Authorized Official - Last Name:BADWALZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:916-747-8534
Mailing Address - Street 1:11615 PELLICANO DR STE 100
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-6242
Mailing Address - Country:US
Mailing Address - Phone:915-444-8006
Mailing Address - Fax:
Practice Address - Street 1:11615 PELLICANO DR STE 100
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-6242
Practice Address - Country:US
Practice Address - Phone:915-444-8006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-04
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No125Q00000XDental ProvidersOral MedicinistGroup - Single Specialty