Healthcare Provider Details

I. General information

NPI: 1477143444
Provider Name (Legal Business Name): 110 DENTISTRY & ORTHODONTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 HWY 110 N STE A
WHITEHOUSE TX
75791-3112
US

IV. Provider business mailing address

PO BOX 734753
DALLAS TX
75373-3112
US

V. Phone/Fax

Practice location:
  • Phone: 972-590-8809
  • Fax: 972-619-7622
Mailing address:
  • Phone: 972-590-8809
  • Fax: 972-619-7622

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: FAITH GASKINS
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 972-869-3789