Provider Demographics
NPI:1356645774
Name:PERLA ORTHODONTICS PC
Entity Type:Organization
Organization Name:PERLA ORTHODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-413-8899
Mailing Address - Street 1:215 S FM 548 STE A
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-4130
Mailing Address - Country:US
Mailing Address - Phone:972-215-7645
Mailing Address - Fax:888-302-6633
Practice Address - Street 1:692 W PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-4809
Practice Address - Country:US
Practice Address - Phone:972-504-2000
Practice Address - Fax:888-302-6633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX244861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty