Provider Demographics
NPI:1508133224
Name:PEDIATRIC DENTRISTRY OF MANSFIELD,PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTRISTRY OF MANSFIELD,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:C
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS PC
Authorized Official - Phone:817-473-7171
Mailing Address - Street 1:1830 E BROAD ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9161
Mailing Address - Country:US
Mailing Address - Phone:817-473-7171
Mailing Address - Fax:817-473-2594
Practice Address - Street 1:1830 E BROAD ST
Practice Address - Street 2:STE104
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9162
Practice Address - Country:US
Practice Address - Phone:817-473-7171
Practice Address - Fax:817-473-2594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-23
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty