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General NPI Number Information
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NPI Number | 1639542855
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Entity Type | Organization
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Legal Business Name | ELITE DENTAL ASSOCIATES, PLLC
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Dates
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Enumeration Date | 11/10/2015
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Last Update Date | 11/10/2015
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Provider Practice Location Address
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Address Line | 5815 LIVE OAK ST SUITE 103
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City | DALLAS
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State | TX
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Zip | 75214-7310
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Country | US
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Telephone | 814-571-3806
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Fax |
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Provider Business Mailing Address
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Address Line | 7417 WELLCREST DR
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City | DALLAS
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State | TX
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Zip | 75230-4235
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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 | DR. LAWRENCE WONG
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Credential | DMD
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Telephone | 814-571-3806
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 26315
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License Number State | TX
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