Provider Demographics
NPI:1174053680
Name:VAN ALSTYNE FAMILY DENTISTRY PLLC
Entity type:Organization
Organization Name:VAN ALSTYNE FAMILY DENTISTRY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-268-6542
Mailing Address - Street 1:217 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:VAN ALSTYNE
Mailing Address - State:TX
Mailing Address - Zip Code:75495-3420
Mailing Address - Country:US
Mailing Address - Phone:903-482-6339
Mailing Address - Fax:903-385-7255
Practice Address - Street 1:217 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:VAN ALSTYNE
Practice Address - State:TX
Practice Address - Zip Code:75495-3420
Practice Address - Country:US
Practice Address - Phone:903-482-6339
Practice Address - Fax:903-385-7255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38855261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX363943701Medicaid