Provider Demographics
NPI:1568918373
Name:ELISE PRUETT DDS PLLC
Entity Type:Organization
Organization Name:ELISE PRUETT DDS PLLC
Other - Org Name:COPPELL HERITAGE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:PRUETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-304-0891
Mailing Address - Street 1:301 S DENTON TAP RD
Mailing Address - Street 2:STE 110
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019
Mailing Address - Country:US
Mailing Address - Phone:972-304-0891
Mailing Address - Fax:972-304-0893
Practice Address - Street 1:301 S DENTON TAP RD
Practice Address - Street 2:STE 110
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019
Practice Address - Country:US
Practice Address - Phone:972-304-0891
Practice Address - Fax:972-304-0893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX288991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1558791004OtherNPI TYPE 1