Healthcare Provider Details

I. General information

NPI: 1609663830
Provider Name (Legal Business Name): MEMORIAL DENTAL & ORTHODONTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 04/22/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1385 MEMORIAL PKWY STE 5
FATE TX
75189
US

IV. Provider business mailing address

1385 MEMORIAL PKWY STE 5
FATE TX
75189
US

V. Phone/Fax

Practice location:
  • Phone: 972-382-7010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: PAOLA RAMOS
Title or Position: CREDENTIALING TEAM LEAD
Credential:
Phone: 972-869-3789