Provider Demographics
NPI:1366708760
Name:PEDIATRIC DENTISTRY OF COLLEYVILLE, P.A.
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY OF COLLEYVILLE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LORIA
Authorized Official - Middle Name:GUIATAS
Authorized Official - Last Name:NAHATIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-428-7704
Mailing Address - Street 1:4109 BROWN TRL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-3998
Mailing Address - Country:US
Mailing Address - Phone:817-428-7704
Mailing Address - Fax:817-428-8919
Practice Address - Street 1:4109 BROWN TRL
Practice Address - Street 2:SUITE 102
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-3998
Practice Address - Country:US
Practice Address - Phone:817-428-7704
Practice Address - Fax:817-428-8919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QD0000X
TX21802261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1629026430OtherINDIVIDUAL NPI
TX18278OtherDENTAL LICENSE
TX1619010972OtherINDIVIDUAL NPI
TX21802OtherDENTAL LICENSE