Provider Demographics
NPI:1265472047
Name:SYNERGY DENTAL, PLLC
Entity Type:Organization
Organization Name:SYNERGY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KOMSON
Authorized Official - Middle Name:
Authorized Official - Last Name:SUDHIVORASETH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-633-2377
Mailing Address - Street 1:228 WEST CAMPBELL ROAD
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3512
Mailing Address - Country:US
Mailing Address - Phone:972-633-2377
Mailing Address - Fax:972-633-2388
Practice Address - Street 1:228 WEST CAMPBELL ROAD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3512
Practice Address - Country:US
Practice Address - Phone:972-633-2377
Practice Address - Fax:972-633-2388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty