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Provider Information for 1174614739

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1174614739

Calendar   Last Updated:  2007-07-08
  Certification Date: 


Name Value
NPI 1174614739
Enumeration Date 2006-09-27
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 1445 HOLLY STAR DR
TYLER, TX 75703-0977
United States

Phone: 903-939-9942 | Fax: 903-939-0636
View Map External Link
Primary Practice Address 10752 FM 2813
FLINT, TX 75762-3730
United States

Phone: 903-561-4477 | Fax: 903-561-4475
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223G0001X - Dentist General Practice TX 18179