Provider Demographics
NPI:1285868166
Name:CROSS TIMBERS DENTAL, PC
Entity Type:Organization
Organization Name:CROSS TIMBERS DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:REVERING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-355-8500
Mailing Address - Street 1:2240 CROSS TIMBERS ROAD, SUITE 100
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028
Mailing Address - Country:US
Mailing Address - Phone:972-355-8500
Mailing Address - Fax:972-539-3584
Practice Address - Street 1:2240 CROSS TIMBERS ROAD, SUITE 100
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028
Practice Address - Country:US
Practice Address - Phone:972-355-8500
Practice Address - Fax:972-539-3584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX189701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty