Provider Demographics
NPI:1316345341
Name:SOUTH ARLINGTON DENTAL CARE
Entity type:Organization
Organization Name:SOUTH ARLINGTON DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEATRIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:VALDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-860-2222
Mailing Address - Street 1:2313 W ARKANSAS LN
Mailing Address - Street 2:#111
Mailing Address - City:PANTEGO
Mailing Address - State:TX
Mailing Address - Zip Code:76013-6064
Mailing Address - Country:US
Mailing Address - Phone:817-860-2222
Mailing Address - Fax:
Practice Address - Street 1:2313 W ARKANSAS LN
Practice Address - Street 2:#111
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-6064
Practice Address - Country:US
Practice Address - Phone:817-860-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29434122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1194964874Medicaid