Healthcare Provider Details

I. General information

NPI: 1700472099
Provider Name (Legal Business Name): SOUTH WEST FREEWAY FAMILY DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6902 SOUTHWEST FWY
HOUSTON TX
77074-2106
US

IV. Provider business mailing address

5800 N I 35 STE 205
DENTON TX
76207-1438
US

V. Phone/Fax

Practice location:
  • Phone: 940-220-7833
  • Fax:
Mailing address:
  • Phone: 940-220-7833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: EVERETT C EVANS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 940-220-7833