Provider Demographics
NPI:1154326486
Name:PEDIATRIC DENTAL SPECIALISTS, PA
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-892-1200
Mailing Address - Street 1:2921 N HERITAGE PARKWAY
Mailing Address - Street 2:STE 100
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092
Mailing Address - Country:US
Mailing Address - Phone:903-892-1200
Mailing Address - Fax:903-813-1581
Practice Address - Street 1:2921 N HERITAGE PARKWAY
Practice Address - Street 2:STE 100
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092
Practice Address - Country:US
Practice Address - Phone:903-892-1200
Practice Address - Fax:903-813-1581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX183211223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0093EXOtherBLUE CROSS BLUE SHIELD
TX817302OtherUNITED CONCORDIA