Provider Demographics
NPI:1073614772
Name:AMARILLO PEDIATRIC DENTISTRY AND ORTHODONTICS, PLLC
Entity type:Organization
Organization Name:AMARILLO PEDIATRIC DENTISTRY AND ORTHODONTICS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:LYNSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-350-5437
Mailing Address - Street 1:2300 WOLFLIN AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109
Mailing Address - Country:US
Mailing Address - Phone:806-350-5437
Mailing Address - Fax:806-350-5438
Practice Address - Street 1:2300 WOLFLIN AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109
Practice Address - Country:US
Practice Address - Phone:806-398-2536
Practice Address - Fax:806-350-5438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200248890AMedicaid
TX177133901Medicaid
NM29824753Medicaid