Provider Demographics
NPI:1316134125
Name:HOME TOWN DENTAL,PA
Entity type:Organization
Organization Name:HOME TOWN DENTAL,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-237-3222
Mailing Address - Street 1:6332 LAKE WORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3602
Mailing Address - Country:US
Mailing Address - Phone:817-237-3222
Mailing Address - Fax:817-237-0101
Practice Address - Street 1:6332 LAKE WORTH
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TN
Practice Address - Zip Code:76135
Practice Address - Country:US
Practice Address - Phone:817-237-3222
Practice Address - Fax:817-237-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicaid