Provider Demographics
NPI:1295384873
Name:SEAGOVILLE MIRROR LAKE DENTISTRY PLLC
Entity Type:Organization
Organization Name:SEAGOVILLE MIRROR LAKE DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEADERSHIP
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-200-1190
Mailing Address - Street 1:605 AVALON DR
Mailing Address - Street 2:
Mailing Address - City:SEAGOVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75159-3034
Mailing Address - Country:US
Mailing Address - Phone:972-287-5311
Mailing Address - Fax:
Practice Address - Street 1:605 AVALON DR
Practice Address - Street 2:
Practice Address - City:SEAGOVILLE
Practice Address - State:TX
Practice Address - Zip Code:75159-3034
Practice Address - Country:US
Practice Address - Phone:972-287-5311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental