Provider Demographics
NPI:1356517650
Name:AMARILLO DENTAL ASSOCIATES
Entity type:Organization
Organization Name:AMARILLO DENTAL ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:VACLAV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:806-355-7463
Mailing Address - Street 1:4525 VAN WINKLE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119
Mailing Address - Country:US
Mailing Address - Phone:806-355-7463
Mailing Address - Fax:806-355-6014
Practice Address - Street 1:4525 VAN WINKLE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119
Practice Address - Country:US
Practice Address - Phone:806-355-7463
Practice Address - Fax:806-355-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX218341223G0001X, 122300000X
TX10364122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1578606901OtherRYAN STREET DDS
TX0095226-01Medicaid
TX1710020177OtherMICHAEL VACLAV DDS