Healthcare Provider Details

I. General information

NPI: 1902485535
Provider Name (Legal Business Name): GLADE CROSSING DENTAL, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 03/11/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W. GLADE ROAD SUITE 300
GRAPEVINE TX
76051-7535
US

IV. Provider business mailing address

PO BOX 543414
DALLAS TX
75354-3414
US

V. Phone/Fax

Practice location:
  • Phone: 214-420-7000
  • 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 Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ROBERT E TAFEL
Title or Position: OWNER
Credential: DDS
Phone: 214-420-7000