# TEXAS DENTAL IMPLANT CENTER

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1780012203
- **Authorized official:** MS. JESSE LYNN DEITZ RN, MBA (PRACTICE DIRECTOR)
- **Authorized official phone:** (254) 300-8804

## Contact information

- **Practice address:** 1237 COUNTY ROAD 197, JONESBORO, TX 76538-1207
- **Practice address phone:** (910) 922-9644
- **Mailing address:** 1237 COUNTY ROAD 197, JONESBORO, TX 76538-1207

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | — | NULL | — |
| 122300000X | Dentist | — | — | — |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | NULL | Yes |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | — | Yes |

## Other

- **Enumeration date:** 10/18/2013
- **Last updated:** 10/18/2013