Provider Demographics
NPI:1285811364
Name:THE TEXAS CHILDREN'S DENTAL UNIVERSE
Entity type:Organization
Organization Name:THE TEXAS CHILDREN'S DENTAL UNIVERSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELONIE
Authorized Official - Middle Name:RACHEL
Authorized Official - Last Name:DUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS (PEDIATRICS)
Authorized Official - Phone:409-945-8080
Mailing Address - Street 1:1114 14TH ST N
Mailing Address - Street 2:
Mailing Address - City:TEXAS CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77590-5413
Mailing Address - Country:US
Mailing Address - Phone:409-945-8080
Mailing Address - Fax:409-945-4325
Practice Address - Street 1:1114 14TH ST N
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77590-5413
Practice Address - Country:US
Practice Address - Phone:409-945-8080
Practice Address - Fax:409-945-4325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX179821223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG60405-01OtherCHIPS
TX840977OtherUNITED CONCORDIA
TX149758802Medicaid