=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720462971
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | Z/D ANESTHESIA GROUP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2015
-----------------------------------------------------
Last Update Date | 07/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1514 E ABRAM ST SUITE A
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76010-7213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-678-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1614A ABRAM STREET
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-678-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | DAVID MARRERO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-521-6551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 27463
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------