Healthcare Provider Details

I. General information

NPI: 1417687476
Provider Name (Legal Business Name): THRIVE DENTAL FM PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17977 PRESTON RD STE A
DALLAS TX
75252-5661
US

IV. Provider business mailing address

5822 VICKERY BLVD
DALLAS TX
75206-6336
US

V. Phone/Fax

Practice location:
  • Phone: 323-898-3102
  • Fax:
Mailing address:
  • Phone: 310-429-7436
  • 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 Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. NATHAN COUGHLIN
Title or Position: OWNER
Credential: DDS
Phone: 972-248-9119