Basic Information
Provider Information | |||||||||
NPI: | 1376797407 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTH TEXAS DENTAL ASSOCIATES, L.P. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6300 WEST LOOP S STE 650 | ||||||||
Address2: |   | ||||||||
City: | BELLAIRE | ||||||||
State: | TX | ||||||||
PostalCode: | 774012997 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7136637960 | ||||||||
FaxNumber: | 7133498027 | ||||||||
Practice Location | |||||||||
Address1: | 4229 EAST LANCASTER AVE. | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 76103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8174130712 | ||||||||
FaxNumber: | 8174130727 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2008 | ||||||||
LastUpdateDate: | 07/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOMEL | ||||||||
AuthorizedOfficialFirstName: | BARRY | ||||||||
AuthorizedOfficialMiddleName: | JAMES | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICER/PARTNER | ||||||||
AuthorizedOfficialTelephone: | 7136637960 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 16570 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.