Provider Demographics
NPI:1063560514
Name:ORTHODONTIC SPECIALISTS OF SEGUIN, P.A.
Entity type:Organization
Organization Name:ORTHODONTIC SPECIALISTS OF SEGUIN, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:830-372-9811
Mailing Address - Street 1:205 S STATE HIGHWAY 46
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-7504
Mailing Address - Country:US
Mailing Address - Phone:830-372-9811
Mailing Address - Fax:830-303-0149
Practice Address - Street 1:205 S STATE HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-7504
Practice Address - Country:US
Practice Address - Phone:830-372-9811
Practice Address - Fax:830-303-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX159021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty