Provider Demographics
NPI:1740663764
Name:CARUS DENTAL PC
Entity type:Organization
Organization Name:CARUS DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:19121 W LAKE HOUSTON PKWY STE E
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-4826
Mailing Address - Country:US
Mailing Address - Phone:281-446-2153
Mailing Address - Fax:
Practice Address - Street 1:19121 W LAKE HOUSTON PKWY STE E
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-4826
Practice Address - Country:US
Practice Address - Phone:281-446-2153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARUS DENTAL PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-08
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX157691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty