Provider Demographics
NPI:1851036016
Name:ODYSSEY DENTAL ANESTHESIA PA
Entity Type:Organization
Organization Name:ODYSSEY DENTAL ANESTHESIA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:469-215-3494
Mailing Address - Street 1:7504 SAN JACINTO PL
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3233
Mailing Address - Country:US
Mailing Address - Phone:972-789-1234
Mailing Address - Fax:
Practice Address - Street 1:7504 SAN JACINTO PL
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3233
Practice Address - Country:US
Practice Address - Phone:469-215-3494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty