Provider Demographics
NPI:1023276268
Name:SUNRISE MALL F.D.C., P.A.
Entity type:Organization
Organization Name:SUNRISE MALL F.D.C., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:ARMSTRONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-328-4867
Mailing Address - Street 1:5858 S PADRE ISLAND DR
Mailing Address - Street 2:STE 54A
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-3920
Mailing Address - Country:US
Mailing Address - Phone:361-994-4867
Mailing Address - Fax:361-994-1655
Practice Address - Street 1:5858 S PADRE ISLAND DR
Practice Address - Street 2:STE 54A
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-3920
Practice Address - Country:US
Practice Address - Phone:361-994-4867
Practice Address - Fax:361-994-1655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0008481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty