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General NPI Number Information
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NPI Number | 1871876680
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Entity Type | Organization
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Legal Business Name | EVERGREEN DENTAL P A
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Dates
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Enumeration Date | 09/28/2011
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Last Update Date | 09/28/2011
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Provider Practice Location Address
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Address Line | 225 E STATE HIGHWAY 121 STE 117
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City | COPPELL
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State | TX
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Zip | 75019-2008
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Country | US
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Telephone | 972-315-0811
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Fax | 972-315-0891
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Provider Business Mailing Address
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Address Line | 225 E STATE HIGHWAY 121 STE 117
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City | COPPELL
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State | TX
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Zip | 75019-2008
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Country | US
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Telephone | 972-315-0811
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Fax | 972-315-0891
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Authorized Official
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Title or Position | OWNER
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Name | DR. HEEJE LEE
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Credential | D.D.S.
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Telephone | 972-315-0811
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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 | 25602
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License Number State | TX
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