Healthcare Provider Details

I. General information

NPI: 1740989094
Provider Name (Legal Business Name): 3220 GUS THOMASSON RD. DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 02/27/2023
Certification Date: 02/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 GUS THOMASSON RD STE 347
MESQUITE TX
75150-4051
US

IV. Provider business mailing address

4801 S BUCKNER BLVD STE 800
DALLAS TX
75227-2377
US

V. Phone/Fax

Practice location:
  • Phone: 972-698-6685
  • Fax:
Mailing address:
  • Phone: 214-275-4808
  • Fax: 281-916-6479

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: MARIA ESTRADA
Title or Position: BILLING/CREDENTIALING MANAGER
Credential:
Phone: 214-275-4808