Provider Demographics
NPI:1386988491
Name:ABC DENTAL PLLC
Entity type:Organization
Organization Name:ABC DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-563-7633
Mailing Address - Street 1:101 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160-2644
Mailing Address - Country:US
Mailing Address - Phone:972-563-7633
Mailing Address - Fax:972-551-0840
Practice Address - Street 1:101 E HIGH ST
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160-2644
Practice Address - Country:US
Practice Address - Phone:972-563-7633
Practice Address - Fax:972-551-0840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198096301Medicaid