1093058471 NPI number — FAMILY DENTAL OF MCKINNEY

Table of content: (NPI 1093058471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093058471 NPI number — FAMILY DENTAL OF MCKINNEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY DENTAL OF MCKINNEY
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:
1093058471
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1321 N TENNESSEE ST
Provider Second Line Business Mailing Address:
STE.108
Provider Business Mailing Address City Name:
MCKINNEY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75069-2142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-742-0793
Provider Business Mailing Address Fax Number:
469-742-9937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1321 N. TENNESSEE ST.
Provider Second Line Business Practice Location Address:
STE.108
Provider Business Practice Location Address City Name:
MCKINNEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-742-0793
Provider Business Practice Location Address Fax Number:
469-742-9937
Provider Enumeration Date:
04/03/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
THAMMASITHIBOON
Authorized Official First Name:
IRENE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWENER
Authorized Official Telephone Number:
469-742-0793

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  25969 , 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)