Provider Demographics
NPI:1962827758
Name:ABC123 DENTAL IN CROWLEY PLLC
Entity Type:Organization
Organization Name:ABC123 DENTAL IN CROWLEY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-496-2343
Mailing Address - Street 1:6426 MEADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-5123
Mailing Address - Country:US
Mailing Address - Phone:817-496-2343
Mailing Address - Fax:817-665-3822
Practice Address - Street 1:200 E MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-2600
Practice Address - Country:US
Practice Address - Phone:817-496-2343
Practice Address - Fax:817-665-3822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24570305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1558597963Medicaid