Healthcare Provider Details

I. General information

NPI: 1356732184
Provider Name (Legal Business Name): JERRY H HIDLEBAUGH DDS AND ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2015
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 E WEAVER AVE
ALVARADO TX
76009-4375
US

IV. Provider business mailing address

202 E WEAVER AVE
ALVARADO TX
76009-4375
US

V. Phone/Fax

Practice location:
  • Phone: 817-783-2173
  • Fax: 817-783-2632
Mailing address:
  • Phone: 817-783-2173
  • Fax: 817-783-2632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8188
License Number StateTX

VIII. Authorized Official

Name: MRS. WENDY BRICE
Title or Position: OWNER
Credential:
Phone: 817-783-2173