Provider Demographics
NPI:1235340365
Name:FLOWER MOUND DENTISTRY DIVINE
Entity Type:Organization
Organization Name:FLOWER MOUND DENTISTRY DIVINE
Other - Org Name:FLOWER MOUND FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIAMESHA
Authorized Official - Middle Name:MICHALLE
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-539-4290
Mailing Address - Street 1:2200 MORRISS RD STE 150
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-3239
Mailing Address - Country:US
Mailing Address - Phone:972-539-4290
Mailing Address - Fax:972-355-1736
Practice Address - Street 1:2200 MORRISS RD STE 150
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-3239
Practice Address - Country:US
Practice Address - Phone:972-539-4290
Practice Address - Fax:972-355-1736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15884261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1144438060OtherINDIVIDUAL PIN NUMBER