Provider Demographics
NPI:1114477353
Name:CARUS DENTAL PC
Entity type:Organization
Organization Name:CARUS DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:16000 PARK VALLEY DR STE 160
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4009
Mailing Address - Country:US
Mailing Address - Phone:512-733-8308
Mailing Address - Fax:512-310-0451
Practice Address - Street 1:16000 PARK VALLEY DR STE 160
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4009
Practice Address - Country:US
Practice Address - Phone:512-733-8308
Practice Address - Fax:512-310-0451
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARUS DENTAL PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-12
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX159191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty