Provider Demographics
NPI:1245890300
Name:TOOTH PLACE PSJA, PLLC
Entity type:Organization
Organization Name:TOOTH PLACE PSJA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:SLOVAK
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-542-9200
Mailing Address - Street 1:300 LORENALY DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-4060
Mailing Address - Country:US
Mailing Address - Phone:956-542-9200
Mailing Address - Fax:888-418-0123
Practice Address - Street 1:826 W US HIGHWAY 83
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-2139
Practice Address - Country:US
Practice Address - Phone:956-542-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty