Provider Demographics
NPI:1295976082
Name:FOURTH DIMENSION ORTHODONTICS & CRANIOFACIAL ORTHOPEDICS, PLLC
Entity type:Organization
Organization Name:FOURTH DIMENSION ORTHODONTICS & CRANIOFACIAL ORTHOPEDICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEJI
Authorized Official - Middle Name:V
Authorized Official - Last Name:FASHEMO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:361-985-0964
Mailing Address - Street 1:7717 OUTREAU DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-6148
Mailing Address - Country:US
Mailing Address - Phone:361-985-0964
Mailing Address - Fax:
Practice Address - Street 1:7717 OUTREAU DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-6148
Practice Address - Country:US
Practice Address - Phone:361-985-0964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216391223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty