Provider Demographics
NPI:1194134577
Name:PEARSALL DENTAL PLLC-PA
Entity type:Organization
Organization Name:PEARSALL DENTAL PLLC-PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:ABDULNAIM
Authorized Official - Last Name:ABAZID
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-846-5571
Mailing Address - Street 1:1809 LOUISE LANE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PEARSALL
Mailing Address - State:TX
Mailing Address - Zip Code:78061-3207
Mailing Address - Country:US
Mailing Address - Phone:210-846-5571
Mailing Address - Fax:
Practice Address - Street 1:1809 LOUISE LANE
Practice Address - Street 2:SUITE 200
Practice Address - City:PEARSALL
Practice Address - State:TX
Practice Address - Zip Code:78061-3215
Practice Address - Country:US
Practice Address - Phone:210-846-5571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26095122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218209907Medicaid