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Provider Information for 1790852382

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1790852382

Calendar   Last Updated:  2018-04-13
  Certification Date: 


Name Value
NPI 1790852382
Enumeration Date 2006-11-29
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 14628 N 142ND LN
SURPRISE, AZ 85379-8728
United States

Phone: 623-975-9543 | Fax:
View Map External Link
Primary Practice Address 5520 INDEPENDENCE PKWY STE 200
FRISCO, TX 75035-4607
United States

Phone: 121-438-3095 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223X0400X - Dentist Orthodontics and Dentofacial Orthopedics TX TX25136