Healthcare Provider Details

I. General information

NPI: 1720386824
Provider Name (Legal Business Name): TERRY FAMILY DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2011
Last Update Date: 03/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 CORKY BOYD AVE
WILLS POINT TX
75169-2815
US

IV. Provider business mailing address

209 CORKY BOYD AVE
WILLS POINT TX
75169-2815
US

V. Phone/Fax

Practice location:
  • Phone: 903-873-2523
  • Fax: 903-873-4405
Mailing address:
  • Phone: 903-873-2523
  • Fax: 903-873-4405

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: RANDELL SHANE TERRY
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 903-873-2523