Basic Information
Provider Information | |||||||||
NPI: | 1538556824 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUMMIT DENTAL CENTER, L.P. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1812 DURHAM DR | ||||||||
Address2: | SUITE A | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770072256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8326730999 | ||||||||
FaxNumber: | 2816472406 | ||||||||
Practice Location | |||||||||
Address1: | 2327 SW MILITARY DR | ||||||||
Address2: | SUITE 102 | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782241428 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2109275561 | ||||||||
FaxNumber: | 2109270023 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2015 | ||||||||
LastUpdateDate: | 04/24/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KAWAJA | ||||||||
AuthorizedOfficialFirstName: | ESSA | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | DENTIST/OWNER | ||||||||
AuthorizedOfficialTelephone: | 8326730999 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | SR. | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 17989 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 193400000X | 01 | TX | DENTAL | OTHER |