Healthcare Provider Details

I. General information

NPI: 1386052751
Provider Name (Legal Business Name): VMAX DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2014
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N PRESTON RD SUITE 10
PROSPER TX
75078-8643
US

IV. Provider business mailing address

110 N PRESTON RD SUITE 10
PROSPER TX
75078-8643
US

V. Phone/Fax

Practice location:
  • Phone: 972-346-2080
  • Fax: 972-346-3551
Mailing address:
  • Phone: 972-346-2080
  • Fax: 972-346-3551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number20894
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number21239
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number18320
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21656
License Number StateTX

VIII. Authorized Official

Name: DR. THOMAS RUSSELL CHANDLER
Title or Position: DENTIST
Credential: DDS, FAGD
Phone: 817-681-4580