Basic Information
| Provider Information | |||||||||
| NPI: | 1073832291 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAGLE DENTAL P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12609 S. GESSNER DRIVE | ||||||||
| Address2: | STE. F | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770712803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137746700 | ||||||||
| FaxNumber: | 7137746704 | ||||||||
| Practice Location | |||||||||
| Address1: | 12609 S GESSNER DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770712803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137746700 | ||||||||
| FaxNumber: | 7137746704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 06/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | ODIA | ||||||||
| AuthorizedOfficialFirstName: | DAVIN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8327902223 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUN DENTAL GROUP P.A. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 22575 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 190960801 | 05 | TX | MEDICAID | B22575-01 | 01 | CHIP | OTHER | 214288701 | 05 | TX | MEDICAID | B22575-02 | 01 | CHIP | OTHER |