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4573 Lake Shore Dr Waco TX 76710-1814 | |
| (817) 656-1215 | |
| (877) 230-8349 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 4573 Lake Shore Dr, Waco, Texas |
| Authorized Official Name and Position | Tri Pham (SOLE OWNER) |
| Authorized Official Contact | 8176561215 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
5416 Basswood Blvd Fort Worth TX 76137-4400 Ph: (817) 656-1215 | 4573 Lake Shore Dr Waco TX 76710-1814 Ph: (817) 656-1215 |
| NPI Number | 1760842587 |
|---|---|
| Provider Enumeration Date | 03/07/2016 |
| Last Update Date | 05/08/2024 |
| Medicare PECOS PAC ID | 1557805819 |
|---|---|
| Medicare Enrollment ID | O20240627004203 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1760842587 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 24570 (Texas) | Secondary |
| 261QD0000X | Clinic/center - Dental | (* (Not Available)) | Primary |
| Provider Name | Tri Huu Pham |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1558597963 PECOS PAC ID: 7012271778 Enrollment ID: I20180514001679 |
| Provider Name | James Edmondson |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1013094606 PECOS PAC ID: 7810200409 Enrollment ID: I20240714000075 |
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