MEDICARE: GREAT SOUTHWEST FAMILY DENTAL PROFESSIONAL ASSOCIATION

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	1223G0001X	General Practice Dentistry	220394	TX

General Provider Information

NPI Number	:	1386962660
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT SOUTHWEST FAMILY DENTAL PROFESSIONAL ASSOCIATION

Provider Business Mailing Address
First Line	:	2501 W I 20
Second Line	:	SUITE 100
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3947
Country	:	US
Telephone Number	:	972-660-8457
Fax Number	:

Provider Business Practice Location Address
First Line	:	2501 W I 20
Second Line	:	SUITE 100
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3947
Country	:	US
Telephone Number	:	972-660-8457
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHRIS H TRUONG
Credential	:
Telephone Number	:	972-660-8457

Provider Enumeration Date	:	05/11/2010
Last Update Date	:	10/06/2025

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