=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023123569
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH GARLAND FAMILY DENTAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1309 BELTLINE RD STE A
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-530-7979
-----------------------------------------------------
Fax | 972-530-6434
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1309 BELTLINE RD STE A
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-530-7979
-----------------------------------------------------
Fax | 972-530-6434
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. NANCY L HENRICHSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-530-7979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22745
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22043
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------