Provider Demographics
NPI:1679118996
Name:WAXAHACHIE MODERN DENTISTRY, PC
Entity Type:Organization
Organization Name:WAXAHACHIE MODERN DENTISTRY, PC
Other - Org Name:WAXAHACHIE MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:DO-YABUT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:469-712-2960
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N HIGHWAY 77 STE 300
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-7847
Practice Address - Country:US
Practice Address - Phone:469-712-2960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-11
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty