Provider Demographics
NPI:1043662885
Name:MISSION EAST DALLAS AND METROPLEX PROJECT, INC.
Entity Type:Organization
Organization Name:MISSION EAST DALLAS AND METROPLEX PROJECT, INC.
Other - Org Name:MISSOIN EAST DALLAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILTRAUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-349-7319
Mailing Address - Street 1:2914 OATES DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-3914
Mailing Address - Country:US
Mailing Address - Phone:972-682-8917
Mailing Address - Fax:
Practice Address - Street 1:4550 GUS THOMASSON RD
Practice Address - Street 2:SUITE #26
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-1700
Practice Address - Country:US
Practice Address - Phone:972-682-8917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty