Provider Demographics
NPI:1083337240
Name:CONCHO VALLEY FAMILY DENTAL
Entity type:Organization
Organization Name:CONCHO VALLEY FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:FANDEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:602-466-5687
Mailing Address - Street 1:2102 PECOS ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3061
Mailing Address - Country:US
Mailing Address - Phone:325-944-4984
Mailing Address - Fax:
Practice Address - Street 1:2102 PECOS ST STE 1
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3061
Practice Address - Country:US
Practice Address - Phone:325-944-4984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty