Healthcare Provider Details

I. General information

NPI: 1407863806
Provider Name (Legal Business Name): AUSTIN RYAN CHURCH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 TREASURE HILLS BLVD
HARLINGEN TX
78550-8911
US

IV. Provider business mailing address

5700 EDWARDS RANCH RD STE 100
FORT WORTH TX
76109-4128
US

V. Phone/Fax

Practice location:
  • Phone: 956-365-6003
  • Fax: 956-365-6780
Mailing address:
  • Phone: 817-292-2004
  • Fax: 817-292-7083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22241
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22241
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: