MEDICARE: IDEAL DENTAL OF GRAND PRAIRIE PLLC

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
1	122300000X	Dentist

General Provider Information

NPI Number	:	1528569019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL DENTAL OF GRAND PRAIRIE PLLC

Provider Business Mailing Address
First Line	:	PO BOX 840925
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-0925
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3450 S HWY 161
Second Line	:	SUITE 200
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-1438
Country	:	US
Telephone Number	:	972-820-7214
Fax Number	:	972-739-2400

Authorized Official
Title or Position	:	OWNER
Name	:	RODNEY ALLES
Credential	:	DDS
Telephone Number	:	972-331-8079

Provider Enumeration Date	:	02/21/2018
Last Update Date	:	05/19/2023

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