Provider Demographics
NPI:1710283767
Name:DISTINCTIVE DENTAL SERVICES
Entity Type:Organization
Organization Name:DISTINCTIVE DENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARRON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBLISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-297-0337
Mailing Address - Street 1:210 ABNER JACKSON PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5124
Mailing Address - Country:US
Mailing Address - Phone:979-297-0337
Mailing Address - Fax:979-297-5003
Practice Address - Street 1:210 ABNER JACKSON PKWY
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5124
Practice Address - Country:US
Practice Address - Phone:979-297-0337
Practice Address - Fax:979-297-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty