MEDICARE: SPARKLE DENTAL CENTER - GRAND

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	21736	TX

General Provider Information

NPI Number	:	1609183912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARKLE DENTAL CENTER - GRAND

Provider Business Mailing Address
First Line	:	5429 E GRAND AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75223-1914
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5429 E GRAND AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75223-1914
Country	:	US
Telephone Number	:	214-342-9600
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TUAN ANH NGUYEN
Credential	:
Telephone Number	:	469-831-0890

Provider Enumeration Date	:	09/08/2010
Last Update Date	:	09/08/2010

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