NPI age
19 years
Enumerated 2006-10-20
Across 935 active dentist providers in Texas.
| Type | Value | Notes |
|---|---|---|
| 01 (TX) | 16399 | STATE LICENSE # |
| 01 (TX) | 5395637 | AETNA PROVIDER ID# |
| 01 (TX) | 86D552 | BC/BS PROVIDER# |
Part of a multi-provider practice. 3 other active providers share this practice address in NPPES.
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