Provider Demographics
NPI:1518275619
Name:MOBILE GENTLE DENTISTRY PLLC
Entity Type:Organization
Organization Name:MOBILE GENTLE DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:VO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-519-8427
Mailing Address - Street 1:820 S MACARTHUR BLVD
Mailing Address - Street 2:105-363
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-4216
Mailing Address - Country:US
Mailing Address - Phone:214-519-8427
Mailing Address - Fax:
Practice Address - Street 1:820 S MACARTHUR BLVD
Practice Address - Street 2:105-363
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-4216
Practice Address - Country:US
Practice Address - Phone:214-519-8427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX232731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184801206Medicaid