Provider Demographics
NPI:1215591391
Name:MANOR TOTAL DENTAL AND ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:MANOR TOTAL DENTAL AND ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:GASKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:2403 LACY LANE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006
Mailing Address - Country:US
Mailing Address - Phone:972-869-3789
Mailing Address - Fax:972-590-8809
Practice Address - Street 1:11828 RING DR. STE 102
Practice Address - Street 2:
Practice Address - City:MANOR
Practice Address - State:TX
Practice Address - Zip Code:78653
Practice Address - Country:US
Practice Address - Phone:512-649-3339
Practice Address - Fax:512-243-6838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies