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General NPI Number Information
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NPI Number | 1609111889
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Entity Type | Organization
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Legal Business Name | ALLURE DENTAL OF GRAPEVINE PA
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Dates
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Enumeration Date | 11/29/2012
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Last Update Date | 11/29/2012
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Provider Practice Location Address
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Address Line | 2805 E GRAPEVINE MILLS CIR SUITE 180
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City | GRAPEVINE
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State | TX
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Zip | 76051-1210
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Country | US
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Telephone | 972-355-8688
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Fax |
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Provider Business Mailing Address
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Address Line | 2805 E GRAPEVINE MILLS CIR SUITE 180
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City | GRAPEVINE
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State | TX
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Zip | 76051-1210
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Country | US
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Telephone | 972-355-8688
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | MARCUS LASTIMADO
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Credential | DMD
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Telephone | 972-355-8688
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 23570
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License Number State | TX
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