Basic Information
| Provider Information | |||||||||
| NPI: | 1043754740 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREECE CHURCH AND ASSOCIATES, PEDIATRIC DENTISTRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 EDWARDS RANCH RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761094127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172922004 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5700 EDWARDS RANCH RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761094127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172922004 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2016 | ||||||||
| LastUpdateDate: | 12/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | PREECE | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | STANLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8172922004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 17828 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 1407863806 | 01 | NPI, TYPE 1 | OTHER | 1881949592 | 01 | NPI, TYPE 1 | OTHER | 2168825-01 | 05 | TX | MEDICAID | 0912362-03 | 05 | TX | MEDICAID | 3608952-01 | 05 | TX | MEDICAID | 1245251362 | 01 | TX | NPI, TYPE 1 | OTHER |