Provider Demographics
NPI:1255689394
Name:MISTRY, WANDANA
Entity Type:Individual
Prefix:DR
First Name:WANDANA
Middle Name:
Last Name:MISTRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 CONOVER DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1519
Mailing Address - Country:US
Mailing Address - Phone:214-590-0193
Mailing Address - Fax:
Practice Address - Street 1:801 CONOVER DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1519
Practice Address - Country:US
Practice Address - Phone:214-590-0193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28344122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist