Provider Demographics
NPI:1265885057
Name:COLUMBUS CHILDREN'S DENTISTRY PLLC
Entity type:Organization
Organization Name:COLUMBUS CHILDREN'S DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:979-733-8844
Mailing Address - Street 1:106 SHULT DR STE AB
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:TX
Mailing Address - Zip Code:78934-3016
Mailing Address - Country:US
Mailing Address - Phone:979-733-8844
Mailing Address - Fax:
Practice Address - Street 1:106 SHULT DR STE AB
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:TX
Practice Address - Zip Code:78934-3016
Practice Address - Country:US
Practice Address - Phone:979-733-8844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-18
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27076261QD0000X
122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX27076OtherDENTAL LICENSE