Provider Demographics
NPI:1679277735
Name:SPECIALTY ORTHODONTICS, PC
Entity type:Organization
Organization Name:SPECIALTY ORTHODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SERENTHES
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-271-4001
Mailing Address - Street 1:1500 S A W GRIMES BLVD STE 190
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7843
Mailing Address - Country:US
Mailing Address - Phone:512-271-4001
Mailing Address - Fax:512-233-5180
Practice Address - Street 1:608 GATEWAY CENTRAL STE 201
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-6356
Practice Address - Country:US
Practice Address - Phone:512-271-4001
Practice Address - Fax:512-233-5180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty