Provider Demographics
NPI:1578027207
Name:NORTH TEXAS FAMILY AND COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:NORTH TEXAS FAMILY AND COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRUMBOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-360-9944
Mailing Address - Street 1:3260 SOUTHERN DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-1548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3260 SOUTHERN DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-1548
Practice Address - Country:US
Practice Address - Phone:972-360-9944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX18458OtherLICENSE