Provider Demographics
NPI:1063566198
Name:ICS DENTAL PA
Entity type:Organization
Organization Name:ICS DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-717-9300
Mailing Address - Street 1:2310 E SAUNDERS ST
Mailing Address - Street 2:STE 102
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-5435
Mailing Address - Country:US
Mailing Address - Phone:956-717-9300
Mailing Address - Fax:956-717-9307
Practice Address - Street 1:2310 E SAUNDERS ST
Practice Address - Street 2:STE 102
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-5435
Practice Address - Country:US
Practice Address - Phone:956-717-9300
Practice Address - Fax:956-717-9307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty