Provider Demographics
NPI:1942840004
Name:MACK DENTAL
Entity Type:Organization
Organization Name:MACK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADKISSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-236-4050
Mailing Address - Street 1:3008 H G MOSLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2948
Mailing Address - Country:US
Mailing Address - Phone:903-236-4050
Mailing Address - Fax:903-753-4426
Practice Address - Street 1:3008 H G MOSLEY PKWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2948
Practice Address - Country:US
Practice Address - Phone:903-236-4050
Practice Address - Fax:903-753-4426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental