Healthcare Provider Details

I. General information

NPI: 1619252293
Provider Name (Legal Business Name): TEXAS GRINS FAMILY DENTISTRY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 EL CHICO TRL SUITE 101
WILLOW PARK TX
76087-8863
US

IV. Provider business mailing address

136 EL CHICO TRL SUITE 101
WILLOW PARK TX
76087-8863
US

V. Phone/Fax

Practice location:
  • Phone: 817-441-3232
  • Fax: 817-441-2230
Mailing address:
  • Phone: 817-441-3232
  • Fax: 817-441-2230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number22460
License Number StateTX

VIII. Authorized Official

Name: DR. CHRISTOPHER RYAN CRAIN
Title or Position: OWNER
Credential: DDS
Phone: 817-441-3232