Provider Demographics
NPI:1699016691
Name:MAX TEJA DDA PA
Entity Type:Organization
Organization Name:MAX TEJA DDA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEHBOOB
Authorized Official - Middle Name:
Authorized Official - Last Name:TEJA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:325-223-2373
Mailing Address - Street 1:4331 COLLEGE HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6919
Mailing Address - Country:US
Mailing Address - Phone:325-223-2373
Mailing Address - Fax:
Practice Address - Street 1:4331 COLLEGE HILLS BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6919
Practice Address - Country:US
Practice Address - Phone:325-223-2373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-15
Last Update Date:2015-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16797261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental