Provider Demographics
NPI:1326564295
Name:WEST CAMPBELL ROAD DENTAL, PLLC
Entity Type:Organization
Organization Name:WEST CAMPBELL ROAD DENTAL, PLLC
Other - Org Name:NORTH RICHARDSON DENTISTRY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:COUNTRYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-308-7079
Mailing Address - Street 1:610 OLD CAMPBELL RD STE 116
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3379
Mailing Address - Country:US
Mailing Address - Phone:972-231-2576
Mailing Address - Fax:
Practice Address - Street 1:610 OLD CAMPBELL RD STE 116
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3379
Practice Address - Country:US
Practice Address - Phone:972-231-2576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1326254772OtherGENERAL
TX1417203407OtherGENERAL
TX1053576447OtherGENERAL