Provider Demographics
NPI:1679694038
Name:TEXAS DENTAL GROUP
Entity Type:Organization
Organization Name:TEXAS DENTAL GROUP
Other - Org Name:CONROEDENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:OSAMOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:936-760-3050
Mailing Address - Street 1:608 EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-1829
Mailing Address - Country:US
Mailing Address - Phone:936-760-3050
Mailing Address - Fax:936-441-3068
Practice Address - Street 1:608 EVERETT ST
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-1829
Practice Address - Country:US
Practice Address - Phone:936-760-3050
Practice Address - Fax:936-441-3068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21886122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty