Provider Demographics
NPI:1376041764
Name:DAYTON DENTAL PLLC
Entity Type:Organization
Organization Name:DAYTON DENTAL PLLC
Other - Org Name:SMILE CLUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-368-1495
Mailing Address - Street 1:1261 W GREEN OAKS BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-8349
Mailing Address - Country:US
Mailing Address - Phone:940-368-1495
Mailing Address - Fax:
Practice Address - Street 1:400 E HIGHWAY 90 STE 402
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TX
Practice Address - Zip Code:77535-2630
Practice Address - Country:US
Practice Address - Phone:936-681-8592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX243481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty