Provider Demographics
NPI:1386913283
Name:CARUS DENTAL PC
Entity type:Organization
Organization Name:CARUS DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:105 WILDWOOD DR
Mailing Address - Street 2:SUITE 216
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78633-1343
Mailing Address - Country:US
Mailing Address - Phone:512-942-6729
Mailing Address - Fax:512-942-6846
Practice Address - Street 1:105 WILDWOOD DR
Practice Address - Street 2:SUITE 216
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633-1343
Practice Address - Country:US
Practice Address - Phone:512-942-6729
Practice Address - Fax:512-942-6846
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARUS DENTAL PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-21
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX136871223G0001X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty