Basic Information
| Provider Information | |||||||||
| NPI: | 1891925491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TREGEAGLE | ||||||||
| FirstName: | THADDEUS | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TREGEAGLE | ||||||||
| OtherFirstName: | THAD | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DDS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9135 SCHAEFER RD | ||||||||
| Address2: | 3 | ||||||||
| City: | CONVERSE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781091979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106078232 | ||||||||
| FaxNumber: | 2103682132 | ||||||||
| Practice Location | |||||||||
| Address1: | 9135 SCHAEFER RD | ||||||||
| Address2: | 3 | ||||||||
| City: | CONVERSE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106078232 | ||||||||
| FaxNumber: | 2103682132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2009 | ||||||||
| LastUpdateDate: | 09/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 26566 | TX | Y | Dental Providers | Dentist |
No ID Information.