Provider Demographics
NPI:1073940011
Name:PURELY DENTAL GROUP PLLC S-CORP
Entity Type:Organization
Organization Name:PURELY DENTAL GROUP PLLC S-CORP
Other - Org Name:FATE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-804-5624
Mailing Address - Street 1:7406 STATE HIGHWAY 66
Mailing Address - Street 2:
Mailing Address - City:ROYSE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75189
Mailing Address - Country:US
Mailing Address - Phone:972-460-4422
Mailing Address - Fax:
Practice Address - Street 1:7406 STATE HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:ROYSE CITY
Practice Address - State:TX
Practice Address - Zip Code:75189
Practice Address - Country:US
Practice Address - Phone:972-460-4422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-05
Last Update Date:2013-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25750122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty