=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093137192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONE STAR DENTAL AND BRACES DALLAS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2014
-----------------------------------------------------
Last Update Date | 09/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2509 S HAMPTON RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75224-1623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-331-4867
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2509 S HAMPTON RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75224-1623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-331-4867
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GERALD SHERRICK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 214-331-4867
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 25574
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------