1710244546 NPI number — MESQUITE ENDODONTICS, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710244546 NPI number — MESQUITE ENDODONTICS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MESQUITE ENDODONTICS, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710244546
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 678074
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75267-8074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-270-4456
Provider Business Mailing Address Fax Number:
972-270-4042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1534 E INTERSTATE 30
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
GARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75043-4788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-270-4456
Provider Business Practice Location Address Fax Number:
972-270-4042
Provider Enumeration Date:
04/18/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DEES
Authorized Official First Name:
LORI
Authorized Official Middle Name:
ANNA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
972-270-4456

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  20068 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)