Provider Demographics
NPI:1093000804
Name:FRESH DENTAL PLLC
Entity Type:Organization
Organization Name:FRESH DENTAL PLLC
Other - Org Name:FRESH DENTAL & ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PU
Authorized Official - Suffix:
Authorized Official - Credentials:
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 1:3873 HWY 64 W
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75704-6925
Practice Address - Country:US
Practice Address - Phone:972-869-3789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-09
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty