Provider Demographics
NPI:1083473722
Name:MYDENTAL AT MANOR PLLC
Entity Type:Organization
Organization Name:MYDENTAL AT MANOR PLLC
Other - Org Name:MYDENTAL AT MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JINAL
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-815-3663
Mailing Address - Street 1:12836 US HIGHWAY 290 E STE 500
Mailing Address - Street 2:
Mailing Address - City:MANOR
Mailing Address - State:TX
Mailing Address - Zip Code:78653-5522
Mailing Address - Country:US
Mailing Address - Phone:512-815-3663
Mailing Address - Fax:
Practice Address - Street 1:12836 HIGHWAY 290 E, SUITE 500
Practice Address - Street 2:
Practice Address - City:MANOR
Practice Address - State:TX
Practice Address - Zip Code:78653
Practice Address - Country:US
Practice Address - Phone:512-815-3663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-15
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty