Provider Demographics
NPI:1275904641
Name:DESOTO DENTAL PLLC
Entity Type:Organization
Organization Name:DESOTO DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHESH
Authorized Official - Middle Name:BABU
Authorized Official - Last Name:GONDI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-750-0610
Mailing Address - Street 1:3200 PARKWOOD BLVD
Mailing Address - Street 2:#310
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8750
Mailing Address - Country:US
Mailing Address - Phone:972-750-0610
Mailing Address - Fax:
Practice Address - Street 1:116 W PARKERVILLE RD
Practice Address - Street 2:STE # 112
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115
Practice Address - Country:US
Practice Address - Phone:972-750-0610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22213261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental