Healthcare Provider Details

I. General information

NPI: 1912380650
Provider Name (Legal Business Name): ACRE WOOD DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 BELLMEAD DR
WACO TX
76705-3138
US

IV. Provider business mailing address

9821 CHAPEL RD #2011
WACO TX
76712-8200
US

V. Phone/Fax

Practice location:
  • Phone: 254-799-5461
  • Fax:
Mailing address:
  • Phone: 208-220-6589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KISHA FUENTES
Title or Position: OFFICE MANAGER
Credential:
Phone: 254-778-4951