Provider Demographics
NPI:1669667408
Name:DENTAL ETC
Entity type:Organization
Organization Name:DENTAL ETC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:713-703-2915
Mailing Address - Street 1:2945 GULF FWY S STE D
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6771
Mailing Address - Country:US
Mailing Address - Phone:281-534-7300
Mailing Address - Fax:281-534-7299
Practice Address - Street 1:2945 GULF FWY S STE D
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6771
Practice Address - Country:US
Practice Address - Phone:281-534-7300
Practice Address - Fax:281-534-7299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167196802Medicaid