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General NPI Number Information
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NPI Number | 1003351271
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Entity Type | Organization
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Legal Business Name | GLEN ROSE FAMILY DENTAL
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Dates
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Enumeration Date | 12/27/2016
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Last Update Date | 12/27/2016
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Provider Practice Location Address
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Address Line | 1104 BLUEBONNET ST
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City | GLEN ROSE
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State | TX
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Zip | 76043-5013
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Country | US
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Telephone | 254-898-4646
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Fax | 254-897-7321
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Provider Business Mailing Address
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Address Line | 1104 BLUEBONNET ST
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City | GLEN ROSE
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State | TX
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Zip | 76043-5013
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Country | US
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Telephone | 254-898-4646
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Fax | 254-897-7321
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | DR. CLAYTON K COOK
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Credential | DMD
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Telephone | 254-898-4646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 29154
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License Number State | TX
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