Provider Demographics
NPI:1033779731
Name:PEDIATRIC DENTAL CARE, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHTFOOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-702-0708
Mailing Address - Street 1:15660 DALLAS PKWY STE 925
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-3323
Mailing Address - Country:US
Mailing Address - Phone:214-702-0729
Mailing Address - Fax:
Practice Address - Street 1:1300 CROP CIR
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-4945
Practice Address - Country:US
Practice Address - Phone:214-702-0729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-17
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty