Basic Information
| Provider Information | |||||||||
| NPI: | 1407863806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHURCH | ||||||||
| FirstName: | AUSTIN | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 EDWARDS RANCH RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761094128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172922004 | ||||||||
| FaxNumber: | 8172927083 | ||||||||
| Practice Location | |||||||||
| Address1: | 1706 TREASURE HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | HARLINGEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785508911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563656003 | ||||||||
| FaxNumber: | 9563656780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 22241 | TX | N | Dental Providers | Dentist | General Practice | 1223P0221X | 22241 | TX | Y | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.