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General NPI Number Information
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NPI Number | 1154440089
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Entity Type | Organization
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Legal Business Name | BROAD PARK FAMILY DENTISTRY
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Dates
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Enumeration Date | 03/29/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1750 E BROAD ST
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City | MANSFIELD
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State | TX
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Zip | 76063-3400
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Country | US
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Telephone | 817-473-6857
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Fax |
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Provider Business Mailing Address
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Address Line | 1750 E BROAD ST
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City | MANSFIELD
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State | TX
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Zip | 76063-3400
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Country | US
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Telephone | 817-473-6857
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DAX MICHAEL SINN
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Credential | DDS
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Telephone | 817-473-6857
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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 | D21075
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License Number State | TX
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