Provider Demographics
NPI:1861651291
Name:PROFESSIONAL ORTHODONTIC ASSOCIATES PC
Entity type:Organization
Organization Name:PROFESSIONAL ORTHODONTIC ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-230-0155
Mailing Address - Street 1:701 N HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-4509
Mailing Address - Country:US
Mailing Address - Phone:972-230-0155
Mailing Address - Fax:972-230-0741
Practice Address - Street 1:701 N HAMPTON RD
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4509
Practice Address - Country:US
Practice Address - Phone:972-230-0155
Practice Address - Fax:972-230-0741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX84951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty