Provider Demographics
NPI:1407397144
Name:GBCC DENTAL PLLC
Entity Type:Organization
Organization Name:GBCC DENTAL PLLC
Other - Org Name:GLEN ROSE FAMILY DENTAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:K
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:817-294-1090
Mailing Address - Street 1:1104 BLUEBONNET ST
Mailing Address - Street 2:
Mailing Address - City:GLEN ROSE
Mailing Address - State:TX
Mailing Address - Zip Code:76043
Mailing Address - Country:US
Mailing Address - Phone:254-898-4646
Mailing Address - Fax:254-897-7321
Practice Address - Street 1:1104 BLUEBONNET ST
Practice Address - Street 2:
Practice Address - City:GLEN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043
Practice Address - Country:US
Practice Address - Phone:254-898-4646
Practice Address - Fax:254-897-7321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-14
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty