Basic Information
| Provider Information | |||||||||
| NPI: | 1871934794 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH TEXAS DENTAL ASSOCIATES, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6300 WEST LOOP S STE 650 | ||||||||
| Address2: | |||||||||
| City: | BELLAIRE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774012997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134573445 | ||||||||
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| Practice Location | |||||||||
| Address1: | 817 W JEFFERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752084924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149415777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2013 | ||||||||
| LastUpdateDate: | 07/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | GOMEL | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7134573445 | ||||||||
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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 | 16570 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.