Provider Demographics
NPI:1447638077
Name:PANTEGO DENTIST, PLLC
Entity type:Organization
Organization Name:PANTEGO DENTIST, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-630-2193
Mailing Address - Street 1:301 S BOWEN RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-1255
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 S BOWEN RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-1255
Practice Address - Country:US
Practice Address - Phone:817-339-6140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043393572OtherNATIONAL PLAN AND PROVIDER ENUMERATION SYSTEM
TX1700978079OtherNATIONAL PLAN AND PROVIDER ENUMERATION SYSTEM