Provider Demographics
NPI:1639633480
Name:EMPIRE DENTAL
Entity Type:Organization
Organization Name:EMPIRE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SEEMA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-944-6969
Mailing Address - Street 1:6307 GRANADA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1733
Mailing Address - Country:US
Mailing Address - Phone:443-944-6969
Mailing Address - Fax:
Practice Address - Street 1:1915 ROGERS ROAD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-7825
Practice Address - Country:US
Practice Address - Phone:443-944-6969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX29662OtherTEXAS LICENSE