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General NPI Number Information
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NPI Number | 1508133224
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTRISTRY OF MANSFIELD,PLLC
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Dates
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Enumeration Date | 11/23/2011
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Last Update Date | 12/30/2014
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Provider Practice Location Address
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Address Line | 1830 E BROAD ST STE104
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City | MANSFIELD
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State | TX
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Zip | 76063-9162
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Country | US
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Telephone | 817-473-7171
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Fax | 817-473-2594
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Provider Business Mailing Address
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Address Line | 1830 E BROAD ST STE 104
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City | MANSFIELD
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State | TX
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Zip | 76063-9161
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Country | US
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Telephone | 817-473-7171
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Fax | 817-473-2594
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Authorized Official
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Title or Position | OWNER
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Name | DEBORAH C. SULLIVAN
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Credential | DDS, MS PC
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Telephone | 817-473-7171
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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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