Provider Demographics
NPI:1760842587
Name:AFFORDABLE DENTIST NEAR ME IN WACO PLLC
Entity Type:Organization
Organization Name:AFFORDABLE DENTIST NEAR ME IN WACO PLLC
Other - Org Name:AFFORDABLE DENTIST NEAR ME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRI
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-656-1215
Mailing Address - Street 1:5416 BASSWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-4400
Mailing Address - Country:US
Mailing Address - Phone:817-656-1215
Mailing Address - Fax:877-230-8349
Practice Address - Street 1:4573 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-1814
Practice Address - Country:US
Practice Address - Phone:817-656-1215
Practice Address - Fax:877-230-8349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX245701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty