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Provider Information for 1861520645

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: 1861520645

Calendar   Last Updated:  2016-03-28
  Certification Date: 


Name Value
NPI 1861520645
Enumeration Date 2007-03-01
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 2240 MARKET PLACE BLVD STE 140
IRVING, TX 75063-8098
United States

Phone: 972-556-0600 | Fax: 972-556-0600
View Map External Link
Primary Practice Address 2240 MARKET PLACE BLVD SUITE 140
IRVING, TX 75063-8072
United States

Phone: 214-257-0708 | 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 1223G0001X - Dentist General Practice TX 23031