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General NPI Number Information
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NPI Number | 1285994483
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Entity Type | Organization
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Legal Business Name | JSN DENTAL PLLC
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Dates
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Enumeration Date | 05/22/2012
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Last Update Date | 05/22/2012
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Provider Practice Location Address
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Address Line | 8849 N TARRANT PKWY SUITE# 105
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City | NORTH RICHLAND HILLS
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State | TX
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Zip | 76182-7695
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Country | US
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Telephone | 817-381-1122
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Fax |
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Provider Business Mailing Address
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Address Line | 10611 FAULKNER PT
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City | IRVING
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State | TX
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Zip | 75063-5429
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Country | US
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Telephone | 858-231-0299
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. SUGUNA GOTTAM
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Credential | DDS
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Telephone | 817-381-1122
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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 | 23460
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License Number State | TX
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