=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760938450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEGUIN DENTALCARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2016
-----------------------------------------------------
Last Update Date | 09/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1417 E WALNUT ST SUITE 100
-----------------------------------------------------
City | SEGUIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78155-5182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-600-1782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1417 E WALNUT ST SUITE 100
-----------------------------------------------------
City | SEGUIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78155-5182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PRASHANTKUMAR GAJERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 200-600-1782
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 29185
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------