Provider Demographics
NPI:1699090100
Name:CHILDREN'S DENTAL SERVICES OF TEXAS, PLLC
Entity type:Organization
Organization Name:CHILDREN'S DENTAL SERVICES OF TEXAS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-731-8600
Mailing Address - Street 1:PO BOX 55367
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-5367
Mailing Address - Country:US
Mailing Address - Phone:214-533-8183
Mailing Address - Fax:
Practice Address - Street 1:4545 BELLAIRE DR S STE 4
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-1811
Practice Address - Country:US
Practice Address - Phone:817-731-8600
Practice Address - Fax:817-207-0719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX204651223P0221X
1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210915901Medicaid