Provider Demographics
NPI:1851569297
Name:CC DENTAL PC
Entity Type:Organization
Organization Name:CC DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TY
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:SHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-737-8731
Mailing Address - Street 1:PO BOX 93653
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0115
Mailing Address - Country:US
Mailing Address - Phone:817-737-8731
Mailing Address - Fax:817-763-9342
Practice Address - Street 1:1051 HASKELL ST
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-737-8731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental