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General NPI Number Information
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NPI Number | 1881005296
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Entity Type | Organization
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Legal Business Name | PORT LAVACA DENTISTRY PLLC
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Dates
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Enumeration Date | 05/20/2014
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Last Update Date | 12/04/2025
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Provider Practice Location Address
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Address Line | 1606 N VIRGINIA ST
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City | PORT LAVACA
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State | TX
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Zip | 77979
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Country | US
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Telephone | 361-552-5800
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Fax | 888-276-1646
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Provider Business Mailing Address
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Address Line | ATTN: CREDENTIALING 2403 LACY LANE
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City | CARROLLTON
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State | TX
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Zip | 75006
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Country | US
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Telephone | 972-869-3789
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Fax | 888-276-1646
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Authorized Official
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Title or Position | PAYER ENROLLMENT TEAM LEAD
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Name | PAOLA LOPEZ
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Credential |
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Telephone | 972-869-3789
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 27025
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License Number State | TX
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