Provider Demographics
NPI:1649645268
Name:1488 DENTAL CLINICS INC
Entity type:Organization
Organization Name:1488 DENTAL CLINICS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MBACHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OKWEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MBA
Authorized Official - Phone:936-242-1490
Mailing Address - Street 1:469 FM 1488 RD
Mailing Address - Street 2:STE 103
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77384-4188
Mailing Address - Country:US
Mailing Address - Phone:936-242-1490
Mailing Address - Fax:936-242-1388
Practice Address - Street 1:469 FM 1488 RD
Practice Address - Street 2:STE 103
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77384-4188
Practice Address - Country:US
Practice Address - Phone:936-242-1490
Practice Address - Fax:936-242-1388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty