Provider Demographics
NPI:1861106114
Name:AGAVE DENTAL FUN ZONE PLLC
Entity type:Organization
Organization Name:AGAVE DENTAL FUN ZONE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:KASALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:915-833-0303
Mailing Address - Street 1:6309 NATALICIO LN
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-1859
Mailing Address - Country:US
Mailing Address - Phone:915-204-6941
Mailing Address - Fax:
Practice Address - Street 1:10501 GATEWAY BLVD W STE 107
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7956
Practice Address - Country:US
Practice Address - Phone:915-204-6941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental