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General NPI Number Information
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NPI Number | 1730676735
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Entity Type | Organization
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Legal Business Name | FORNEY MIRROR LAKE DENTISTRY PLLC
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Dates
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Enumeration Date | 04/16/2018
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Last Update Date | 04/16/2018
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Provider Practice Location Address
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Address Line | 845 N. FM 548 SUITE 150
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City | FORNEY
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State | TX
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Zip | 75126
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Country | US
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Telephone | 972-200-1190
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Fax |
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Provider Business Mailing Address
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Address Line | 845 N. FM 548 SUITE 150
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City | FORNEY
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State | TX
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Zip | 75126
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Country | US
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Telephone | 972-200-1190
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | JUSTIN HUMPHRIES
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Credential |
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Telephone | 972-200-1190
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 29699
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License Number State | TX
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