Provider Demographics
NPI:1295499739
Name:AGAVE DENTAL CARE NORTH EAST, PLLC
Entity type:Organization
Organization Name:AGAVE DENTAL CARE NORTH EAST, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:915-755-7697
Mailing Address - Street 1:8815 DYER ST SUITE 210
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904
Mailing Address - Country:US
Mailing Address - Phone:915-755-7697
Mailing Address - Fax:915-751-1056
Practice Address - Street 1:8815 DYER ST SUITE 210
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79904
Practice Address - Country:US
Practice Address - Phone:915-755-7697
Practice Address - Fax:915-751-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty