Healthcare Provider Details

I. General information

NPI: 1952742470
Provider Name (Legal Business Name): ENDODONTIC SPECIALISTS OF ROCKWALL BAMF DENTAL PLLC SOLE MBR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 ARISTA DR STE 101
ROCKWALL TX
75032-6657
US

IV. Provider business mailing address

1215 ARISTA DR STE 101
ROCKWALL TX
75032-6657
US

V. Phone/Fax

Practice location:
  • Phone: 469-698-7668
  • Fax: 469-698-7670
Mailing address:
  • Phone: 469-698-7668
  • Fax: 469-698-7670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number23811
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number23811
License Number StateTX

VIII. Authorized Official

Name: CAROL RIOJAS
Title or Position: HR
Credential:
Phone: 817-529-8151