MEDICARE: BRACKETS DENTAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1093126039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRACKETS DENTAL PLLC

Provider Business Mailing Address
First Line	:	15110 DALLAS PKWY
Second Line	:	470
City	:	DALLAS
State	:	TX
Zip	:	75248-4635
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2701 S HAMPTON RD
Second Line	:	201
City	:	DALLAS
State	:	TX
Zip	:	75224-2367
Country	:	US
Telephone Number	:	469-608-8327
Fax Number	:

Authorized Official
Title or Position	:	D.D.S./OWNER
Name	:	GLORIA GURROLA
Credential	:
Telephone Number	:	972-512-0285

Provider Enumeration Date	:	05/13/2014
Last Update Date	:	05/13/2014

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