Healthcare Provider Details

I. General information

NPI: 1841735685
Provider Name (Legal Business Name): WOW DENTAL OF DUNCANVILLE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3306 W CAMP WISDOM RD SUITE 100
DALLAS TX
75237-2596
US

IV. Provider business mailing address

3306 W CAMP WISDOM RD SUITE 100
DALLAS TX
75237-2596
US

V. Phone/Fax

Practice location:
  • Phone: 954-288-8582
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22329
License Number StateTX

VIII. Authorized Official

Name: DR. ZACHARY KINGSBERG
Title or Position: OWNER
Credential:
Phone: 954-288-8582