Provider Demographics
NPI:1669899357
Name:ABC123 DENTAL IN CROWLEY LLC
Entity type:Organization
Organization Name:ABC123 DENTAL IN CROWLEY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:VO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-297-4068
Mailing Address - Street 1:200 E MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-2600
Mailing Address - Country:US
Mailing Address - Phone:817-297-4068
Mailing Address - Fax:877-230-8349
Practice Address - Street 1:200 E MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-2600
Practice Address - Country:US
Practice Address - Phone:817-297-4068
Practice Address - Fax:877-230-8349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty