Healthcare Provider Details

I. General information

NPI: 1861718934
Provider Name (Legal Business Name): KATY TRAIL DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2010
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4152 BUENA VISTA ST
DALLAS TX
75204-7813
US

IV. Provider business mailing address

17480 DALLAS PKWY SUITE 213
DALLAS TX
75287-7337
US

V. Phone/Fax

Practice location:
  • Phone: 214-520-1112
  • Fax: 214-520-1190
Mailing address:
  • Phone: 972-248-1221
  • Fax: 972-248-1072

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: G. SCOTT MARSHALL
Title or Position: OWNER/PARTNER
Credential: DDS
Phone: 903-455-2942