Provider Demographics
NPI:1982970109
Name:BASIN PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:BASIN PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-275-2214
Mailing Address - Street 1:711 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:ANDREWS
Mailing Address - State:TX
Mailing Address - Zip Code:79714-3616
Mailing Address - Country:US
Mailing Address - Phone:432-523-3194
Mailing Address - Fax:
Practice Address - Street 1:711 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:TX
Practice Address - Zip Code:79714-3616
Practice Address - Country:US
Practice Address - Phone:432-523-3194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-02
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX239891223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty