Provider Demographics
NPI:1790408227
Name:IVORY PEDIATRIC DENTAL
Entity Type:Organization
Organization Name:IVORY PEDIATRIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER/PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHIDIACONO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-406-2025
Mailing Address - Street 1:311 S FM 1187 STE 300
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-6452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:311 S FM 1187 STE 300
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:TX
Practice Address - Zip Code:76008-6452
Practice Address - Country:US
Practice Address - Phone:817-406-2025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty