=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255892881
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAI DENTAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2019
-----------------------------------------------------
Last Update Date | 03/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 N MURPHY RD # 100
-----------------------------------------------------
City | MURPHY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-812-9198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1216 AMY DR
-----------------------------------------------------
City | ALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75013-3356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-812-9198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. CHIA-YIN TAI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 202-812-9198
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------