Provider Demographics
NPI:1003186495
Name:COUNTRY DAY DENTAL
Entity Type:Organization
Organization Name:COUNTRY DAY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-731-9487
Mailing Address - Street 1:4255 BRYANT IRVIN RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4233
Mailing Address - Country:US
Mailing Address - Phone:817-731-9487
Mailing Address - Fax:817-731-2846
Practice Address - Street 1:4255 BRYANT IRVIN RD
Practice Address - Street 2:SUITE 111
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4233
Practice Address - Country:US
Practice Address - Phone:817-731-9487
Practice Address - Fax:817-731-2846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12997261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental