Healthcare Provider Details

I. General information

NPI: 1770850273
Provider Name (Legal Business Name): WOW DENTAL-OAKCLIFF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 STATE HIGHWAY 161 STE 198
IRVING TX
75039-2880
US

IV. Provider business mailing address

7301 STATE HIGHWAY 161 STE 198
IRVING TX
75039-2880
US

V. Phone/Fax

Practice location:
  • Phone: 972-869-3789
  • Fax: 972-869-3791
Mailing address:
  • Phone: 972-869-3789
  • Fax: 972-869-3791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MARY PU
Title or Position: VP OF FINANCE
Credential:
Phone: 972-869-3789