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General NPI Number Information
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NPI Number | 1720228893
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Entity Type | Organization
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Legal Business Name | PREMIUM DENTAL
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Dates
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Enumeration Date | 03/02/2009
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Last Update Date | 12/21/2022
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Provider Practice Location Address
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Address Line | 721 I-35 E SOUTH SUITE #206
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City | DENTON
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State | TX
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Zip | 76205-3918
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Country | US
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Telephone | 512-689-4587
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 734753
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City | DALLAS
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State | TX
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Zip | 75373-4753
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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 | CO-OWNER
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Name | SUSAN TRAN
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Credential | D.D.S
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Telephone | 512-689-4587
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 22717
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License Number State | TX
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