Provider Demographics
NPI:1023521309
Name:DENTAL HEALTH ASSOCIATES OF TEXAS, PC
Entity type:Organization
Organization Name:DENTAL HEALTH ASSOCIATES OF TEXAS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:715 N 64TH ST
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-4387
Mailing Address - Country:US
Mailing Address - Phone:254-772-3922
Mailing Address - Fax:
Practice Address - Street 1:715 N 64TH ST
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4387
Practice Address - Country:US
Practice Address - Phone:254-772-3922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL HEALTH ASSOCIATES OF TEXAS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty