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General NPI Number Information
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NPI Number | 1649768979
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Entity Type | Organization
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Legal Business Name | VILLAGE PERIODONTICS & IMPLANT DENT
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Dates
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Enumeration Date | 04/23/2018
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Last Update Date | 04/23/2018
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Provider Practice Location Address
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Address Line | 2820 VILLAGE PKWY STE 630
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City | HIGHLAND VILLAGE
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State | TX
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Zip | 75077-3299
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Country | US
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Telephone | 972-966-2500
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Fax | 972-471-9833
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Provider Business Mailing Address
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Address Line | 2820 VILLAGE PKWY STE 630
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City | HIGHLAND VILLAGE
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State | TX
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Zip | 75077-3299
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Country | US
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Telephone | 972-966-2500
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Fax | 972-471-9833
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JANE C MOORE
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Credential |
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Telephone | 972-966-2500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 16373
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License Number State | TX
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