Healthcare Provider Details

I. General information

NPI: 1871964122
Provider Name (Legal Business Name): UNIVERSITY OF DALLAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2015
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 E NORTHGATE DR MAHER ATHLETIC CENTER
IRVING TX
75062-4736
US

IV. Provider business mailing address

5050 SPRING VALLEY RD
DALLAS TX
75244-3995
US

V. Phone/Fax

Practice location:
  • Phone: 972-721-5010
  • Fax:
Mailing address:
  • Phone: 800-555-9073
  • Fax: 972-367-3452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MOUZON BASS III
Title or Position: AGENT
Credential:
Phone: 972-367-4845