=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780132811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIME FAMILY DENTISTRY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2016
-----------------------------------------------------
Last Update Date | 09/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5204 S COLONY BLVD STE 150
-----------------------------------------------------
City | THE COLONY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75056-2390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-625-2361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5204 S COLONY BLVD STE 150
-----------------------------------------------------
City | THE COLONY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75056-2390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-625-2361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID J ROSSEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 972-625-2361
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 14887
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------