Healthcare Provider Details

I. General information

NPI: 1558437228
Provider Name (Legal Business Name): ACADEMY DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 E MAIN ST
LITTLE RIVER ACADEMY TX
76554-2605
US

IV. Provider business mailing address

PO BOX 546
LITTLE RIVER ACADEMY TX
76554-0546
US

V. Phone/Fax

Practice location:
  • Phone: 254-982-4750
  • Fax: 254-982-4721
Mailing address:
  • Phone: 254-982-4750
  • Fax: 254-982-4721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14945
License Number StateTX

VIII. Authorized Official

Name: DR. JAMES W KNOTT III
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 254-982-4750