Provider Demographics
NPI:1730265653
Name:DENTAL GROUP, PC
Entity type:Organization
Organization Name:DENTAL GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARILU
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-439-1234
Mailing Address - Street 1:1841 POST OAK PARK DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-3303
Mailing Address - Country:US
Mailing Address - Phone:713-439-1234
Mailing Address - Fax:409-744-4541
Practice Address - Street 1:5934 BROADWAY
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77551-4305
Practice Address - Country:US
Practice Address - Phone:409-740-7744
Practice Address - Fax:409-744-4541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1980153-01Medicaid