Provider Demographics
NPI:1487173258
Name:SOMERICA DENTAL, PC
Entity type:Organization
Organization Name:SOMERICA DENTAL, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:OWEN
Authorized Official - Last Name:DAAB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-259-1250
Mailing Address - Street 1:2906 S BAGDAD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-3269
Mailing Address - Country:US
Mailing Address - Phone:512-259-1250
Mailing Address - Fax:
Practice Address - Street 1:2906 S BAGDAD RD STE 100
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-3269
Practice Address - Country:US
Practice Address - Phone:512-259-1250
Practice Address - Fax:512-259-1250
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOMERICA DENTAL PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX305451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty