Provider Demographics
NPI:1710011259
Name:AIRLINE DENTAL CLINIC
Entity type:Organization
Organization Name:AIRLINE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:IRASEMA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-697-2631
Mailing Address - Street 1:1257 ARCHLEY DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-6706
Mailing Address - Country:US
Mailing Address - Phone:713-464-3326
Mailing Address - Fax:
Practice Address - Street 1:5990 AIRLINE DR
Practice Address - Street 2:SUITE 180
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77076-4233
Practice Address - Country:US
Practice Address - Phone:713-694-8333
Practice Address - Fax:713-694-8362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX168421223G0001X
TX225581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169622101Medicaid
TX177617101Medicaid
TX009806301Medicaid