Basic Information
| Provider Information | |||||||||
| NPI: | 1710174883 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DENTISTRY OF BROWNSVILLE, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KOOL SMILES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1090 NORTHCHASE PKWY SE STE 150 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300676407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709165028 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 432 S BIBB AVE | ||||||||
| Address2: | |||||||||
| City: | EAGLE PASS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709169000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2007 | ||||||||
| LastUpdateDate: | 03/22/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAYFIELD | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | GARY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7709165036 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223E0200X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223S0112X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.