Provider Demographics
NPI:1447620554
Name:DENTAL REPUBLIC - BANDERA, PC
Entity type:Organization
Organization Name:DENTAL REPUBLIC - BANDERA, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SON
Authorized Official - Middle Name:NAM
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-960-3535
Mailing Address - Street 1:2515 MCKINNEY AVE
Mailing Address - Street 2:SUITE 940
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-1908
Mailing Address - Country:US
Mailing Address - Phone:214-747-1400
Mailing Address - Fax:214-242-4455
Practice Address - Street 1:5720 BANDERA RD
Practice Address - Street 2:SUITE 22
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-1985
Practice Address - Country:US
Practice Address - Phone:210-888-8308
Practice Address - Fax:210-888-8309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty