Provider Demographics
NPI:1568834711
Name:DISTINCT DENTAL STUDIOS
Entity Type:Organization
Organization Name:DISTINCT DENTAL STUDIOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-200-1589
Mailing Address - Street 1:1370 W BELTLINE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146
Mailing Address - Country:US
Mailing Address - Phone:972-200-1589
Mailing Address - Fax:
Practice Address - Street 1:1370 W BELTLINE RD
Practice Address - Street 2:STE 100
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146
Practice Address - Country:US
Practice Address - Phone:972-200-1589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DISTINCT DENTAL STUDIOS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-28
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX255911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1851602882Medicaid