Healthcare Provider Details

I. General information

NPI: 1174907315
Provider Name (Legal Business Name): PALESTINE DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 OLD ELKHART RD 110
PALESTINE TX
75801-5922
US

IV. Provider business mailing address

PO BOX 674330
DALLAS TX
75267-4330
US

V. Phone/Fax

Practice location:
  • Phone: 903-723-4669
  • Fax:
Mailing address:
  • Phone: 940-808-1970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number23695
License Number StateTX

VIII. Authorized Official

Name: EVERETT C EVANS
Title or Position: OWNER, DDS
Credential: DDS
Phone: 940-808-1970