Healthcare Provider Details

I. General information

NPI: 1104100361
Provider Name (Legal Business Name): AMERICA DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 SWISHER ROAD
HICKORY CREEK TX
75065
US

IV. Provider business mailing address

4550 SWISHER ROAD
HICKORY CREEK TX
75065
US

V. Phone/Fax

Practice location:
  • Phone: 972-999-7342
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22284
License Number StateTX

VIII. Authorized Official

Name: THUAN PHAM
Title or Position: DIRECTOR
Credential: D.D.S
Phone: 972-999-7342