Provider Demographics
NPI:1558985184
Name:INNATE DENTAL PLLC
Entity Type:Organization
Organization Name:INNATE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-842-2012
Mailing Address - Street 1:4708 W PLANO PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5335
Mailing Address - Country:US
Mailing Address - Phone:972-519-0990
Mailing Address - Fax:469-613-0862
Practice Address - Street 1:4708 W PLANO PKWY STE 200
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5335
Practice Address - Country:US
Practice Address - Phone:972-519-0990
Practice Address - Fax:469-613-0862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-29
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty