Healthcare Provider Details

I. General information

NPI: 1992099774
Provider Name (Legal Business Name): SHILOH FAMILY DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17480 DALLAS PKWY SUITE 213
DALLAS TX
75287-7337
US

IV. Provider business mailing address

5011 TROUP HWY SUITE 700
TYLER TX
75707-1917
US

V. Phone/Fax

Practice location:
  • Phone: 972-248-1221
  • Fax: 972-248-1072
Mailing address:
  • Phone: 903-581-5500
  • Fax: 903-581-5510

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: DR. WILLIAM ROBERT JENNINGS
Title or Position: OWNER
Credential: DDS
Phone: 903-581-5500