Basic Information
Provider Information
NPI: 1689235681
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PHANDL
FirstName: MARTIN
MiddleName: D
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5800 N I 35 STE 205
Address2:  
City: DENTON
State: TX
PostalCode: 762071438
CountryCode: US
TelephoneNumber: 9402207833
FaxNumber: 8557315147
Practice Location
Address1: 5709 4TH ST
Address2:  
City: LUBBOCK
State: TX
PostalCode: 794164241
CountryCode: US
TelephoneNumber: 8065875100
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/21/2019
LastUpdateDate: 06/21/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X35229TXY Dental ProvidersDentistGeneral Practice

No ID Information.


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