=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154810240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANTOLIN-SANCHEZ DENTAL GROUP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2018
-----------------------------------------------------
Last Update Date | 05/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 COUNTRY VIEW DR STE 300
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76262-2057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-237-2353
-----------------------------------------------------
Fax | 682-237-2352
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 COUNTRY VIEW DR STE 300
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76262-2057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-237-2353
-----------------------------------------------------
Fax | 682-237-2352
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RHEA ANTOLIN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 682-237-2353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 25428
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------