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General NPI Number Information
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NPI Number | 1063120343
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Entity Type | Organization
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Legal Business Name | FULL SMILE DENTAL HEREFORD, PLLC
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Dates
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Enumeration Date | 11/07/2022
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Last Update Date | 11/07/2022
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Provider Practice Location Address
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Address Line | 809 W PARK AVE
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City | HEREFORD
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State | TX
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Zip | 79045-4001
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Country | US
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Telephone | 806-641-1373
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Fax | 806-353-7077
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Provider Business Mailing Address
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Address Line | 5051 S SONCY RD
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City | AMARILLO
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State | TX
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Zip | 79119-6667
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Country | US
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Telephone | 806-353-1055
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Fax | 806-353-7077
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | JENNIFER WILLIAMS
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Credential | CS
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Telephone | 806-353-1055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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