Provider Demographics
NPI:1942690003
Name:DENTAL HEALTH ASSOCIATES OF TEXAS, PC
Entity Type:Organization
Organization Name:DENTAL HEALTH ASSOCIATES OF TEXAS, PC
Other - Org Name:PECAN GROVE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:1103 FM 359 RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-2013
Mailing Address - Country:US
Mailing Address - Phone:281-342-7050
Mailing Address - Fax:281-342-0015
Practice Address - Street 1:1103 FM 359 RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-2013
Practice Address - Country:US
Practice Address - Phone:281-342-7050
Practice Address - Fax:281-342-0015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL HEALTH ASSOCIATES OF TEXAS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty