Provider Demographics
NPI:1114358876
Name:TOLLESON ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:TOLLESON ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLLESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-416-2200
Mailing Address - Street 1:1050 E STATE HIGHWAY 114
Mailing Address - Street 2:STE 120
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5253
Mailing Address - Country:US
Mailing Address - Phone:817-416-2200
Mailing Address - Fax:
Practice Address - Street 1:1050 E STATE HIGHWAY 114
Practice Address - Street 2:STE 120
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5253
Practice Address - Country:US
Practice Address - Phone:817-416-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty