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General NPI Number Information
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NPI Number | 1447883863
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Entity Type | Organization
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Legal Business Name | CRE8TIVE PEDIATRIC DENTAL GROUP
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Dates
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Enumeration Date | 02/13/2020
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Last Update Date | 02/13/2020
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Provider Practice Location Address
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Address Line | 2201 FORT WORTH AVENUE
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City | DALLAS
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State | TX
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Zip | 75211
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Country | US
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Telephone | 972-544-7524
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Fax |
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Provider Business Mailing Address
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Address Line | 2787 N HOUSTON ST APT 4002
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City | DALLAS
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State | TX
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Zip | 75219-5042
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Country | US
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Telephone | 281-935-8668
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST/OWNER
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Name | DR. JESSICA MARSHALL
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Credential | DDS
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Telephone | 972-544-7524
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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