Provider Demographics
NPI:1154955805
Name:CONGLOMERATE PLLC
Entity type:Organization
Organization Name:CONGLOMERATE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PART-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARESEA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:334-590-4223
Mailing Address - Street 1:1620 GRAND AVENUE PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-2185
Mailing Address - Country:US
Mailing Address - Phone:512-670-8482
Mailing Address - Fax:
Practice Address - Street 1:1620 GRAND AVENUE PKWY STE 130
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-2185
Practice Address - Country:US
Practice Address - Phone:512-670-8482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-02
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty