Basic Information
| Provider Information | |||||||||
| NPI: | 1518496793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANTWELL | ||||||||
| FirstName: | DEVIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5211 W PONTIAC DR | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853089325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017074590 | ||||||||
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| Practice Location | |||||||||
| Address1: | 225 EXCHANGE ST STE D | ||||||||
| Address2: | |||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760284588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174269337 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2017 | ||||||||
| LastUpdateDate: | 06/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 33064 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.