Provider Demographics
NPI:1073386900
Name:ROCKWALL DENTAL PROFESSIONALS
Entity Type:Organization
Organization Name:ROCKWALL DENTAL PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIGETTE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:KOETTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-771-4100
Mailing Address - Street 1:1375 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-4243
Mailing Address - Country:US
Mailing Address - Phone:972-771-4100
Mailing Address - Fax:
Practice Address - Street 1:1375 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-4243
Practice Address - Country:US
Practice Address - Phone:972-771-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty