Basic Information
| Provider Information | |||||||||
| NPI: | 1447476338 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH TEXAS DENTAL ASSOCIATES, L.P. | ||||||||
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| 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: | 225 NE 28TH ST | ||||||||
| Address2: | |||||||||
| City: | FT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761647205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176240044 | ||||||||
| FaxNumber: | 8176240065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 07/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | GOMEL | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7136637960 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 16570 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.