Basic Information
Provider Information | |||||||||
NPI: | 1184723470 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BIOLASE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5960 W PARKER RD | ||||||||
Address2: | STE 278. PMB 227 | ||||||||
City: | PLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 750937767 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9726085000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5960 W PARKER RD | ||||||||
Address2: | STE 278. PMB 227 | ||||||||
City: | PLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 750937767 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9726085000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 04/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SEGAL | ||||||||
AuthorizedOfficialFirstName: | KIM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9726085000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LAT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | ATO529 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.