Provider Demographics
NPI:1003141599
Name:CAVITY CRUSADER PC
Entity type:Organization
Organization Name:CAVITY CRUSADER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-529-7143
Mailing Address - Street 1:4502 RIVER OAKS PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-5080
Mailing Address - Country:US
Mailing Address - Phone:214-703-5490
Mailing Address - Fax:214-703-5474
Practice Address - Street 1:4502 RIVER OAKS PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75044-5080
Practice Address - Country:US
Practice Address - Phone:214-703-5490
Practice Address - Fax:214-703-5474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21061122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty