Provider Demographics
NPI:1811121460
Name:ORTHODONTIC PROFESSIONALS
Entity type:Organization
Organization Name:ORTHODONTIC PROFESSIONALS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRELIA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:MACHADO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:940-295-4188
Mailing Address - Street 1:4030 JUSTIN ROAD (FM 407)
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75077
Mailing Address - Country:US
Mailing Address - Phone:940-295-4188
Mailing Address - Fax:
Practice Address - Street 1:4030 JUSTIN ROAD (FM 407)
Practice Address - Street 2:SUITE 100
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75077
Practice Address - Country:US
Practice Address - Phone:940-295-4188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22303261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental