Healthcare Provider Details

I. General information

NPI: 1164121422
Provider Name (Legal Business Name): 5429 EAST GRAND AVE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 02/27/2023
Certification Date: 02/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5429 E GRAND AVE
DALLAS TX
75223-1914
US

IV. Provider business mailing address

4801 S BUCKNER BLVD STE 800
DALLAS TX
75227-2377
US

V. Phone/Fax

Practice location:
  • Phone: 214-377-7312
  • Fax: 217-377-7360
Mailing address:
  • Phone: 214-275-4808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARIA ESTRADA
Title or Position: BILLING/CREDENTIALING MANAGER
Credential:
Phone: 214-275-4808