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General NPI Number Information
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NPI Number | 1477871259
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Entity Type | Organization
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Legal Business Name | SAINT APOLONIA MEDICAID DENTAL CLINIC NO 2 OF TEXAS PA
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Dates
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Enumeration Date | 05/04/2010
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Last Update Date | 05/04/2010
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Provider Practice Location Address
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Address Line | 106 SHULT DR SUITE A/B
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City | COLUMBUS
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State | TX
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Zip | 78934-3016
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Country | US
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Telephone | 979-733-8844
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Fax | 979-733-8848
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Provider Business Mailing Address
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Address Line | 106 SHULT DR SUITE A/B
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City | COLUMBUS
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State | TX
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Zip | 78934-3016
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Country | US
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Telephone | 979-733-8844
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Fax | 979-733-8848
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. ROSS W ANDERSON
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Credential | D D S
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Telephone | 979-733-8844
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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 |
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License Number State |
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