=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952718645
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRABHDEEP KAUR DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2014
-----------------------------------------------------
Last Update Date | 05/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4712 COLLEYVILLE BLVD #110
-----------------------------------------------------
City | COLLEYVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76034-3996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-428-5111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2604 OLD DENTON RD #112
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75007-5109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-323-5060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 31146
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------