=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194198895
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENCORE DAP FRISCO, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2015
-----------------------------------------------------
Last Update Date | 11/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5858 W. MAIN ST #250
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-335-3131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5858 W. MAIN ST #250
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-335-3131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PC SHAREHOLDER
-----------------------------------------------------
Name | DR. ROY DANIEL SMITH III
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 972-335-3131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | TX12072
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------