Provider Demographics
NPI:1821507427
Name:INDEPENDENCE PLANET ORAL HEALTHCARE, PLLC
Entity Type:Organization
Organization Name:INDEPENDENCE PLANET ORAL HEALTHCARE, PLLC
Other - Org Name:PLANET DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:STAAT
Authorized Official - Suffix:
Authorized Official - Credentials:DENTIST
Authorized Official - Phone:909-648-6198
Mailing Address - Street 1:2395 E DEL MAR BLVD UNIT 452069
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-0185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2438 MONARCH DR STE A-135
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045-6600
Practice Address - Country:US
Practice Address - Phone:909-648-6198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty