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General NPI Number Information
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NPI Number | 1447427422
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Entity Type | Organization
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Legal Business Name | SAINT APOLLONIA MEDICAID DENTAL CLINIC OF TEXAS, PA
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Dates
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Enumeration Date | 05/09/2008
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Last Update Date | 05/09/2008
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Provider Practice Location Address
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Address Line | 1108 N MECHANIC ST
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City | EL CAMPO
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State | TX
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Zip | 77437-3030
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Country | US
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Telephone | 979-541-5400
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Fax | 979-541-5462
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Provider Business Mailing Address
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Address Line | 1108 N MECHANIC ST
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City | EL CAMPO
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State | TX
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Zip | 77437-3030
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Country | US
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Telephone | 979-541-5400
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Fax | 979-541-5462
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROSS WYATT ANDERSON
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Credential | DDS
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Telephone | 979-541-5400
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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 | 20250
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License Number State | TX
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