Provider Demographics
NPI:1417365131
Name:BLVD DENTISTRY
Entity Type:Organization
Organization Name:BLVD DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:2403 LACY LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-6514
Mailing Address - Country:US
Mailing Address - Phone:972-869-3789
Mailing Address - Fax:972-869-3791
Practice Address - Street 1:1343 W 43RD ST STE F
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018-4201
Practice Address - Country:US
Practice Address - Phone:713-812-8080
Practice Address - Fax:713-812-8181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty