Provider Demographics
NPI:1952680837
Name:CRANIOFACIAL PAIN & SLEEP DENTISTRY, PA
Entity Type:Organization
Organization Name:CRANIOFACIAL PAIN & SLEEP DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:O
Authorized Official - Last Name:BLEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:936-634-1333
Mailing Address - Street 1:5032 CHAMPIONS DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-7346
Mailing Address - Country:US
Mailing Address - Phone:936-634-1333
Mailing Address - Fax:936-634-1343
Practice Address - Street 1:3516 PRESTON RD
Practice Address - Street 2:SUITE 600
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8612
Practice Address - Country:US
Practice Address - Phone:972-985-4865
Practice Address - Fax:972-985-7534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7915122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU66128Medicare UPIN