Provider Demographics
NPI:1700204252
Name:LA COSTA DENTAL OF AYERS PA
Entity Type:Organization
Organization Name:LA COSTA DENTAL OF AYERS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TIEN
Authorized Official - Middle Name:DINH
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:817-531-3500
Mailing Address - Street 1:8150 SPRINGWOOD DR # 150B
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-5810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4224 AYERS ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415-5317
Practice Address - Country:US
Practice Address - Phone:817-531-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-02
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty