Provider Demographics
NPI:1881005296
Name:PORT LAVACA DENTISTRY PLLC
Entity type:Organization
Organization Name:PORT LAVACA DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PAYER ENROLLMENT TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:PAOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:ATTN: CREDENTIALING
Mailing Address - Street 2:2403 LACY LANE
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006
Mailing Address - Country:US
Mailing Address - Phone:972-869-3789
Mailing Address - Fax:888-276-1646
Practice Address - Street 1:1606 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979
Practice Address - Country:US
Practice Address - Phone:361-552-5800
Practice Address - Fax:888-276-1646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty