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General NPI Number Information
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NPI Number | 1679118996
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Entity Type | Organization
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Legal Business Name | WAXAHACHIE MODERN DENTISTRY, PC
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Dates
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Enumeration Date | 11/11/2019
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Last Update Date | 02/08/2022
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Provider Practice Location Address
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Address Line | 1400 N HIGHWAY 77 STE 300
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City | WAXAHACHIE
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State | TX
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Zip | 75165-7847
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Country | US
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Telephone | 469-712-2960
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 920050
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City | DALLAS
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State | TX
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Zip | 75392-0050
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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 | OWNER
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Name | DIANA DO-YABUT
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Credential | DMD
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Telephone | 469-712-2960
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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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