Healthcare Provider Details

I. General information

NPI: 1295397610
Provider Name (Legal Business Name): GRAPEVINE KIDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 S MAIN ST
GRAPEVINE TX
76051-5544
US

IV. Provider business mailing address

1230 S MAIN ST
GRAPEVINE TX
76051-5544
US

V. Phone/Fax

Practice location:
  • Phone: 972-258-0758
  • Fax:
Mailing address:
  • Phone: 817-909-2920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. LYLE MATTHEW SCHOFIELD
Title or Position: MANAGING MEMBER
Credential: DDS
Phone: 469-900-5371