Provider Demographics
NPI:1104288372
Name:BROWN MOBILE DENTAL PA
Entity type:Organization
Organization Name:BROWN MOBILE DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-335-5555
Mailing Address - Street 1:8008 CAMP BOWIE W BLVD, STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8008 CAMP BOWIE W BLVD, STE 101
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116
Practice Address - Country:US
Practice Address - Phone:817-335-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15773122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty