Provider Demographics
NPI:1699851972
Name:DENTON OPTOMETRY, INC.
Entity Type:Organization
Organization Name:DENTON OPTOMETRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WIEBELHAUS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:940-484-8857
Mailing Address - Street 1:1309 LYNHURST LN
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-8079
Mailing Address - Country:US
Mailing Address - Phone:940-484-8857
Mailing Address - Fax:940-387-1998
Practice Address - Street 1:2430 S I-35 E
Practice Address - Street 2:SUITE 156
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-4986
Practice Address - Country:US
Practice Address - Phone:940-484-8857
Practice Address - Fax:940-387-1998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-28
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4002T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0192437-01Medicaid
TXU12454Medicare UPIN
TX00E17NMedicare ID - Type Unspecified