=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477143444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 110 DENTISTRY & ORTHODONTICS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2021
-----------------------------------------------------
Last Update Date | 01/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 308 HWY 110 N STE A
-----------------------------------------------------
City | WHITEHOUSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75791-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-590-8809
-----------------------------------------------------
Fax | 972-619-7622
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 734753
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75373-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-590-8809
-----------------------------------------------------
Fax | 972-619-7622
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CREDENTIALING
-----------------------------------------------------
Name | FAITH GASKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-869-3789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------