Healthcare Provider Details

I. General information

NPI: 1063926681
Provider Name (Legal Business Name): CDPT II PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2017
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17194 PRESTON RD STE 160
DALLAS TX
75248-1221
US

IV. Provider business mailing address

17194 PRESTON RD STE 160
DALLAS TX
75248-1221
US

V. Phone/Fax

Practice location:
  • Phone: 214-453-2565
  • Fax:
Mailing address:
  • Phone: 214-453-2565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number29183
License Number StateTX

VIII. Authorized Official

Name: CHARLOTTE V DASCH
Title or Position: SR. OPERATIONS COORDINATOR
Credential:
Phone: 504-638-0303