Healthcare Provider Details

I. General information

NPI: 1780186205
Provider Name (Legal Business Name): EAST DALLAS DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5429 E GRAND AVE
DALLAS TX
75223-1914
US

IV. Provider business mailing address

11627 S LOUISVILLE AVE
TULSA OK
74137-8543
US

V. Phone/Fax

Practice location:
  • Phone: 214-377-7312
  • Fax:
Mailing address:
  • Phone: 918-695-7616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number33767
License Number StateTX

VIII. Authorized Official

Name: DR. JUSTIN MASSEEH EMAMI
Title or Position: OWNER
Credential: DDS
Phone: 918-695-7616