=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699149518
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THREE MILE DENTISTRY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2015
-----------------------------------------------------
Last Update Date | 11/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 W MILE 3 RD
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78573-4181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-437-2220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 902 S AIRPORT DR SUITE 2
-----------------------------------------------------
City | WESLACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78596-6644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. HARJAP SINGH NANVA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-437-2220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 24586
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------