Provider Demographics
NPI:1790902195
Name:ORTHODONTIC CENTERS OF TEXAS, INC
Entity Type:Organization
Organization Name:ORTHODONTIC CENTERS OF TEXAS, INC
Other - Org Name:EAST TEXAS ORTHODONTIC SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:STURRUP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:903-509-4422
Mailing Address - Street 1:212 GRANDE BLVD STE B226
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4231
Mailing Address - Country:US
Mailing Address - Phone:903-509-4422
Mailing Address - Fax:903-509-4420
Practice Address - Street 1:212 GRANDE BLVD STE B226
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4231
Practice Address - Country:US
Practice Address - Phone:903-509-4422
Practice Address - Fax:903-509-4420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty