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General NPI Number Information
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NPI Number | 1992137707
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Entity Type | Organization
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Legal Business Name | FAMILY DENTAL CLINIC, PC
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Dates
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Enumeration Date | 08/02/2013
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Last Update Date | 08/02/2013
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Provider Practice Location Address
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Address Line | 3128 FOREST LN STE. 106
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City | DALLAS
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State | TX
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Zip | 75234-7726
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Country | US
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Telephone | 972-241-4820
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Fax | 972-241-1627
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Provider Business Mailing Address
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Address Line | 3128 FOREST LN STE. 106
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City | DALLAS
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State | TX
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Zip | 75234-7726
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Country | US
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Telephone | 972-241-4820
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Fax | 972-241-1627
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | MRS. LILY B HAILEMESKEL
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Credential |
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Telephone | 469-939-8219
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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 | 12891811
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License Number State | TX
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