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General NPI Number Information
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NPI Number | 1790902195
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Entity Type | Organization
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Legal Business Name | ORTHODONTIC CENTERS OF TEXAS, INC
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 08/13/2008
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Provider Practice Location Address
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Address Line | 212 GRANDE BLVD STE B226
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City | TYLER
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State | TX
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Zip | 75703-4231
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Country | US
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Telephone | 903-509-4422
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Fax | 903-509-4420
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Provider Business Mailing Address
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Address Line | 212 GRANDE BLVD STE B226
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City | TYLER
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State | TX
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Zip | 75703-4231
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Country | US
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Telephone | 903-509-4422
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Fax | 903-509-4420
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. RANDOLPH WILLIAM STURRUP
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Credential | D.D.S., M.S.
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Telephone | 903-509-4422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 8352
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License Number State | TX
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