Provider Demographics
NPI:1780012203
Name:TEXAS DENTAL IMPLANT CENTER
Entity Type:Organization
Organization Name:TEXAS DENTAL IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DEITZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MBA
Authorized Official - Phone:254-300-8804
Mailing Address - Street 1:1237 COUNTY ROAD 197
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76538-1207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1237 COUNTY ROAD 197
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:TX
Practice Address - Zip Code:76538-1207
Practice Address - Country:US
Practice Address - Phone:910-922-9644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty