Basic Information
| Provider Information | |||||||||
| NPI: | 1700260957 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NACOGDOCHES DENTAL PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 674330 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752674330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9408081970 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4610 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | NACOGDOCHES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759651840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365600900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2015 | ||||||||
| LastUpdateDate: | 07/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | EVERETT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER, DDS | ||||||||
| AuthorizedOfficialTelephone: | 9408081970 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 23695 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.