Provider Demographics
NPI:1518548783
Name:FUSION CHILDREN'S DENTISTRY PLLC
Entity Type:Organization
Organization Name:FUSION CHILDREN'S DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NILOOFAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALESSEH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-666-6071
Mailing Address - Street 1:19200 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-2450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19200 PRESTON RD STE 120
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-2450
Practice Address - Country:US
Practice Address - Phone:972-666-4949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty