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General NPI Number Information
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NPI Number | 1396101010
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Entity Type | Organization
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Legal Business Name | VILLAGE DDS PLLC
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Dates
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Enumeration Date | 01/11/2016
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Last Update Date | 01/11/2016
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Provider Practice Location Address
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Address Line | 4041 W WHEATLAND RD SUITE 202
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City | DALLAS
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State | TX
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Zip | 75237-4063
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Country | US
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Telephone | 817-306-1738
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Fax | 817-306-7366
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Provider Business Mailing Address
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Address Line | 4041 W WHEATLAND RD SUITE 202
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City | DALLAS
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State | TX
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Zip | 75237-4063
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Country | US
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Telephone | 817-306-1738
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Fax | 817-306-7366
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Authorized Official
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Title or Position | OWNER
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Name | OMAR FETOUH
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Credential |
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Telephone | 716-348-9855
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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 | 30316
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 24314
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License Number State | TX
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