MEDICARE: DENTAL HEALTH ASSOCIATES OF TEXAS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1023521309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL HEALTH ASSOCIATES OF TEXAS, PC

Provider Business Mailing Address
First Line	:	715 N 64TH ST
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76710-4387
Country	:	US
Telephone Number	:	254-772-3922
Fax Number	:

Provider Business Practice Location Address
First Line	:	715 N 64TH ST
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76710-4387
Country	:	US
Telephone Number	:	254-772-3922
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING TEAM LEAD
Name	:	CASSANDRA PETERSEN
Credential	:
Telephone Number	:	217-540-8972

Provider Enumeration Date	:	11/09/2017
Last Update Date	:	11/09/2017

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