Provider Demographics
NPI:1427545516
Name:HEATH MIRROR LAKE DENTISTRY PLLC
Entity Type:Organization
Organization Name:HEATH MIRROR LAKE DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHRIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-287-5513
Mailing Address - Street 1:605 AVALON DR
Mailing Address - Street 2:
Mailing Address - City:SEAGOVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75159-3034
Mailing Address - Country:US
Mailing Address - Phone:972-287-5513
Mailing Address - Fax:
Practice Address - Street 1:4225 RIDGE RD
Practice Address - Street 2:
Practice Address - City:HEATH
Practice Address - State:TX
Practice Address - Zip Code:75032-5833
Practice Address - Country:US
Practice Address - Phone:972-287-5513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29699261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental