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NPI Code Detail

MEDICARE: DENTAL PROFESSIONALS OF TEXAS, P.A.

MEDICARE: DENTAL PROFESSIONALS OF TEXAS, P.A.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice Dentistry

General Provider Information

NPI Number : 1043712037
Entity Type Code : Organization
Provider Name (Legal Business Name) : DENTAL PROFESSIONALS OF TEXAS, P.A.
Provider Business Mailing Address
First Line : 5044 TENNYSON PKWY STE A
Second Line :
City : PLANO
State : TX
Zip : 75024-2953
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 5044 TENNYSON PKWY STE A
Second Line :
City : PLANO
State : TX
Zip : 75024-2953
Country : US
Telephone Number : 972-378-3601
Fax Number :
Authorized Official
Title or Position : CREDENTIALING TEAM LEAD
Name : CASSANDRA PETERSEN
Credential :
Telephone Number : 217-540-8972
Provider Enumeration Date : 03/06/2018
Last Update Date : 03/06/2018

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