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General NPI Number Information
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NPI Number | 1184230302
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Entity Type | Organization
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Legal Business Name | MI DENTISTA
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Dates
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Enumeration Date | 09/22/2020
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Last Update Date | 04/19/2023
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Provider Practice Location Address
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Address Line | 3101 W DAVIS ST
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City | DALLAS
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State | TX
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Zip | 75211-2921
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Country | US
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Telephone | 469-399-1553
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Fax |
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Provider Business Mailing Address
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Address Line | 3101 W DAVIS ST
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City | DALLAS
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State | TX
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Zip | 75211-2921
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Country | US
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Telephone | 469-399-1553
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | LOAMMI RODRIGUEZ
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Credential |
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Telephone | 214-335-5013
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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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