Provider Demographics
NPI:1922423078
Name:CROWLEY FAMILY DENTAL CENTER
Entity Type:Organization
Organization Name:CROWLEY FAMILY DENTAL CENTER
Other - Org Name:MODERN FAMILY DENTAL HWY 1187
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ODALIS
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:SKUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-297-0058
Mailing Address - Street 1:779 FM 1187 E
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-4346
Mailing Address - Country:US
Mailing Address - Phone:807-297-0058
Mailing Address - Fax:817-297-7811
Practice Address - Street 1:779 FM 1187 E
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-4346
Practice Address - Country:US
Practice Address - Phone:807-297-0058
Practice Address - Fax:817-297-7811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20899302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1235351495OtherDELTA DENTAL
TX1801093844OtherDELTA DENTAL
TX1447431523OtherDELTA DENTAL