Provider Demographics
NPI:1821360983
Name:ROUP DENTAL
Entity Type:Organization
Organization Name:ROUP DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOREAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-341-7500
Mailing Address - Street 1:661 LOUIS HENNA BLVD STE 420
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7408
Mailing Address - Country:US
Mailing Address - Phone:512-341-7500
Mailing Address - Fax:512-341-7753
Practice Address - Street 1:661 LOUIS HENNA BLVD STE 420
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7408
Practice Address - Country:US
Practice Address - Phone:512-341-7500
Practice Address - Fax:512-341-7753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19139122300000X
TX20619122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty