=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295064152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALL VALLEY DENTAL 2, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2009
-----------------------------------------------------
Last Update Date | 12/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 307A N SALINAS BLVD
-----------------------------------------------------
City | DONNA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78537-2929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-687-6453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 312 PECAN BLVD
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78501-2355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL PARTNER
-----------------------------------------------------
Name | DR. JASON A BURKETT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 956-686-5577
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------