=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245942846
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AFFORDABLE DENTIST NEAR ME IN LONGVIEW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2022
-----------------------------------------------------
Last Update Date | 01/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 444 FOREST SQ STE E
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75605-4463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-508-5750
-----------------------------------------------------
Fax | 903-242-8698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 444 FOREST SQ STE E
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75605-4463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-508-5750
-----------------------------------------------------
Fax | 903-242-8698
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | CINTIA RODAWAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-441-1558
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------