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General NPI Number Information
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NPI Number | 1629329891
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Entity Type | Organization
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Legal Business Name | ISMILE DENTAL AT LA GRAN PLAZA, PLLC
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Dates
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Enumeration Date | 09/27/2012
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Last Update Date | 09/27/2012
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Provider Practice Location Address
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Address Line | 4200 SOUTH FWY SUITE 1550
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City | FORT WORTH
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State | TX
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Zip | 76115-1400
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Country | US
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Telephone | 817-924-8000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 16249
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City | FORT WORTH
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State | TX
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Zip | 76162-0249
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | THANH TRUONG
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Credential | DDS
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Telephone | 817-924-8000
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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 | 22611
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License Number State | TX
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