Healthcare Provider Details

I. General information

NPI: 1154760247
Provider Name (Legal Business Name): EAST GRAND FAMILY DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 11/19/2013
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

5429 E GRAND AVE
DALLAS TX
75223-1914
US

V. Phone/Fax

Practice location:
  • Phone: 214-377-7312
  • Fax: 214-377-7360
Mailing address:
  • Phone:
  • Fax: 972-239-0755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number25797
License Number StateTX

VIII. Authorized Official

Name: DR. SHAMIM MOSLEMI
Title or Position: OWNER
Credential: D.D.S.
Phone: 972-668-3003