Provider Demographics
NPI:1083112932
Name:GULFSIDE DENTAL - LA MARQUE PLLC
Entity Type:Organization
Organization Name:GULFSIDE DENTAL - LA MARQUE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:GASKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DIRECTOR
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:PO BOX 734753
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4753
Mailing Address - Country:US
Mailing Address - Phone:972-869-3789
Mailing Address - Fax:
Practice Address - Street 1:2600 FM 1764 RD STE 170
Practice Address - Street 2:
Practice Address - City:LA MARQUE
Practice Address - State:TX
Practice Address - Zip Code:77568-2828
Practice Address - Country:US
Practice Address - Phone:972-590-8809
Practice Address - Fax:972-619-7622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-25
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty