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General NPI Number Information
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NPI Number | 1609132612
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Entity Type | Organization
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Legal Business Name | GULFSIDE DENTAL
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Dates
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Enumeration Date | 04/03/2012
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Last Update Date | 01/31/2022
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Provider Practice Location Address
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Address Line | 4179 DOWLEN RD
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City | BEAUMONT
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State | TX
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Zip | 77706-6852
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Country | US
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Telephone | 972-869-3789
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Fax | 972-869-3791
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Provider Business Mailing Address
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Address Line | PO BOX 734753
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City | DALLAS
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State | TX
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Zip | 75373-2880
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Country | US
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Telephone | 972-869-3789
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Fax | 972-869-3791
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Authorized Official
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Title or Position | VP OF FINANCE
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Name | MARY PU
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Credential |
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Telephone | 972-869-3789
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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 |
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License Number State |
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