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General NPI Number Information
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NPI Number | 1356517650
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Entity Type | Organization
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Legal Business Name | AMARILLO DENTAL ASSOCIATES
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Dates
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Enumeration Date | 05/06/2008
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Last Update Date | 05/26/2011
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Provider Practice Location Address
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Address Line | 4525 VAN WINKLE
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City | AMARILLO
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State | TX
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Zip | 79119
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Country | US
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Telephone | 806-355-7463
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Fax | 806-355-6014
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Provider Business Mailing Address
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Address Line | 4525 VAN WINKLE
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City | AMARILLO
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State | TX
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Zip | 79119
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Country | US
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Telephone | 806-355-7463
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Fax | 806-355-6014
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Authorized Official
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Title or Position | PARTNER
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Name | MICHAEL D VACLAV
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Credential | DDS
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Telephone | 806-355-7463
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 21834
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 21834
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 10364
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License Number State | TX
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