Provider Demographics
NPI:1659085488
Name:JCL DENTAL PLLC
Entity Type:Organization
Organization Name:JCL DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CINTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-399-7106
Mailing Address - Street 1:300 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78957-1437
Mailing Address - Country:US
Mailing Address - Phone:512-237-4420
Mailing Address - Fax:
Practice Address - Street 1:300 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:TX
Practice Address - Zip Code:78957-1437
Practice Address - Country:US
Practice Address - Phone:512-237-4420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3413981-03Medicaid