Provider Demographics
NPI:1912610072
Name:ADVANTAGE DENTAL ORAL HEALTH CENTER OF TEXAS PC
Entity Type:Organization
Organization Name:ADVANTAGE DENTAL ORAL HEALTH CENTER OF TEXAS PC
Other - Org Name:ADVANTAGE DENTAL PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR MANAGER, LICENSING CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SHERRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-999-5014
Mailing Address - Street 1:3322 W END AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-6805
Mailing Address - Country:US
Mailing Address - Phone:629-999-5014
Mailing Address - Fax:
Practice Address - Street 1:8062 FERGUSON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-5848
Practice Address - Country:US
Practice Address - Phone:214-227-7215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-03
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX454521201Medicaid