Provider Demographics
NPI:1104215367
Name:RESTORE DENTAL PLLC
Entity Type:Organization
Organization Name:RESTORE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHESH
Authorized Official - Middle Name:B
Authorized Official - Last Name:GONDI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:903-257-8815
Mailing Address - Street 1:3108 W STATE HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-2435
Mailing Address - Country:US
Mailing Address - Phone:903-257-8815
Mailing Address - Fax:903-900-4184
Practice Address - Street 1:3108 W STATE HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-2435
Practice Address - Country:US
Practice Address - Phone:903-257-8815
Practice Address - Fax:903-900-4184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-12
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222131223G0001X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1306909080OtherNPI
TX1306909080OtherNPI