1508958117 NPI number — KILLEEN FAMILY DENTISTRY

Table of content: (NPI 1508958117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508958117 NPI number — KILLEEN FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KILLEEN FAMILY DENTISTRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508958117
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 E CENTRAL TEXAS EXPY
Provider Second Line Business Mailing Address:
SUITE #302
Provider Business Mailing Address City Name:
KILLEEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76543-5306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-699-6799
Provider Business Mailing Address Fax Number:
254-699-3465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 E CENTRAL TEXAS EXPY
Provider Second Line Business Practice Location Address:
SUITE #302
Provider Business Practice Location Address City Name:
KILLEEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76543-5306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-699-6799
Provider Business Practice Location Address Fax Number:
254-699-3465
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YASSA
Authorized Official First Name:
ANDRE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECT OWNER
Authorized Official Telephone Number:
254-699-6799

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G60488-1 . This is a "TEXAS CHIP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 172223301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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