=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649551524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROWNSVILLE DENTAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2011
-----------------------------------------------------
Last Update Date | 09/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3675 BOCA CHICA BLVD SUITE: A
-----------------------------------------------------
City | BROWNSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-542-5545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3675 BOCA CHICA BLVD STE A
-----------------------------------------------------
City | BROWNSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78521-4484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-542-5545
-----------------------------------------------------
Fax | 956-542-5547
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. VICKY CANTU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-542-5545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 18069
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------