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General NPI Number Information
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NPI Number | 1174181119
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Entity Type | Organization
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Legal Business Name | MC DENTAL LLC
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Dates
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Enumeration Date | 06/04/2019
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Last Update Date | 12/07/2021
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Provider Practice Location Address
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Address Line | 3615 CHARLES HARDY PKWY STE 200
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City | DALLAS
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State | GA
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Zip | 30157-9472
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Country | US
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Telephone | 770-767-5546
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Fax | 770-505-5206
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Provider Business Mailing Address
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Address Line | 702 SW 8TH ST
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City | BENTONVILLE
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State | AR
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Zip | 72716-0445
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Country | US
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Telephone | 479-204-1258
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Fax |
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Authorized Official
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Title or Position | PRESIDENT- WALMART HEALTH DENTAL
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Name | THERESA CHUNG
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Credential |
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Telephone | 707-675-5546
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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