Healthcare Provider Details

I. General information

NPI: 1346306719
Provider Name (Legal Business Name): CHILDREN'S MEDICAL CENTER OF DALLAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 MOTOR ST
DALLAS TX
75235-7701
US

IV. Provider business mailing address

2209 BRADBURY CT
PLANO TX
75093-4351
US

V. Phone/Fax

Practice location:
  • Phone: 214-456-2550
  • Fax:
Mailing address:
  • Phone: 972-378-5148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number465211
License Number StateTX

VIII. Authorized Official

Name: MS. MARY CAMILLE KATEB
Title or Position: PEDIATRIC NURSE PRACTITIONER
Credential: APN
Phone: 972-378-5148