Provider Demographics
NPI:1750567434
Name:LAS PALMAS CHILDREN'S DENTISTRY
Entity type:Organization
Organization Name:LAS PALMAS CHILDREN'S DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA DEJESUS
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-787-3333
Mailing Address - Street 1:7013 SOUTH CAGE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577
Mailing Address - Country:US
Mailing Address - Phone:956-787-3333
Mailing Address - Fax:956-787-7333
Practice Address - Street 1:7013 SOUTH CAGE BLVD.
Practice Address - Street 2:SUITE A
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577
Practice Address - Country:US
Practice Address - Phone:956-787-3333
Practice Address - Fax:956-787-7333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-13
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX143051223G0001X
TX203931223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190342901Medicaid