=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689180309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONICA JAIN DMD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2017
-----------------------------------------------------
Last Update Date | 12/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1517 14TH ST STE A
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75074-6374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-510-0507
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18201 ROEHAMPTON DR APT 613
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75252-5166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-510-0507
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MONICA JAIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-510-0507
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 31494
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------