Healthcare Provider Details

I. General information

NPI: 1609167923
Provider Name (Legal Business Name): GAURAV PURI PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 OLD ELKHART RD STE 110
PALESTINE TX
75801-5922
US

IV. Provider business mailing address

8337 SUMMER PARK DR 8337 SUMMER PARK DRIVE
FORT WORTH TX
76123-1991
US

V. Phone/Fax

Practice location:
  • Phone: 617-281-7941
  • Fax:
Mailing address:
  • Phone: 617-281-7941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number24365
License Number StateTX

VIII. Authorized Official

Name: DR. GAURAV PURI
Title or Position: DIRECTOR
Credential:
Phone: 617-281-7941