Provider Demographics
NPI:1548513013
Name:CONGO DENTAL CLINIC P.A.
Entity type:Organization
Organization Name:CONGO DENTAL CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:AMULFO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-296-2202
Mailing Address - Street 1:7005 PASTOR BAILEY DR.
Mailing Address - Street 2:STE. 103B
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237
Mailing Address - Country:US
Mailing Address - Phone:972-296-2202
Mailing Address - Fax:972-296-2259
Practice Address - Street 1:7005 PASTOR BAILEY DR.
Practice Address - Street 2:STE. 103B
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237
Practice Address - Country:US
Practice Address - Phone:972-296-2202
Practice Address - Fax:972-296-2259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty