Provider Demographics
NPI:1003991662
Name:WALNUT DENTAL, P.A.
Entity Type:Organization
Organization Name:WALNUT DENTAL, P.A.
Other - Org Name:FAREAST VENTURE CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:D
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-699-9800
Mailing Address - Street 1:810 N PLANO RD STE 210
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-3854
Mailing Address - Country:US
Mailing Address - Phone:972-699-9800
Mailing Address - Fax:972-863-9037
Practice Address - Street 1:810 N PLANO RD STE 210
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-3854
Practice Address - Country:US
Practice Address - Phone:972-699-9800
Practice Address - Fax:972-863-9037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX206071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1482721-01Medicaid