Provider Demographics
NPI:1750826608
Name:DERBY DENTAL CARE, PLLC
Entity Type:Organization
Organization Name:DERBY DENTAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHITEHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-485-1472
Mailing Address - Street 1:3410 FAR WEST BLVD
Mailing Address - Street 2:STE 340
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3194
Mailing Address - Country:US
Mailing Address - Phone:512-795-0128
Mailing Address - Fax:512-795-8393
Practice Address - Street 1:3410 FAR WEST BLVD
Practice Address - Street 2:STE 340
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3194
Practice Address - Country:US
Practice Address - Phone:512-795-0128
Practice Address - Fax:512-795-8393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29047122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty