=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770055360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL HEALTH ASSOCIATES OF TX, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2018
-----------------------------------------------------
Last Update Date | 01/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5932 W PARKER RD
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-6425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-985-1580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5932 W PARKER RD STE 600
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-6406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | COURTNEY MONTEITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-8306
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------