Provider Demographics
NPI:1679201024
Name:MY LOCAL TEXAS DENTAL PRACTICE, PLLC
Entity type:Organization
Organization Name:MY LOCAL TEXAS DENTAL PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SILAS
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-353-4903
Mailing Address - Street 1:6110 BARNES RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-2600
Mailing Address - Country:US
Mailing Address - Phone:719-266-2717
Mailing Address - Fax:
Practice Address - Street 1:226 4TH ST
Practice Address - Street 2:
Practice Address - City:SEALY
Practice Address - State:TX
Practice Address - Zip Code:77474-2726
Practice Address - Country:US
Practice Address - Phone:719-266-2717
Practice Address - Fax:719-213-2311
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MY LOCAL TEXAS DENTAL PRACTICE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty