Provider Demographics
NPI:1700665601
Name:DENTAL DELITE PG PA
Entity Type:Organization
Organization Name:DENTAL DELITE PG PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLADAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-398-1234
Mailing Address - Street 1:PO BOX 172198
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75217-1108
Mailing Address - Country:US
Mailing Address - Phone:214-398-1234
Mailing Address - Fax:866-610-0446
Practice Address - Street 1:8222 BRUTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-1902
Practice Address - Country:US
Practice Address - Phone:214-398-1234
Practice Address - Fax:866-610-0446
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL DELITE PG PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1477937167Medicaid
TX1346978376Medicaid
TX1497443980Medicaid