Provider Demographics
NPI:1578148201
Name:PECAN DENTAL AND IMPLANT SOLUTIONS LLC
Entity Type:Organization
Organization Name:PECAN DENTAL AND IMPLANT SOLUTIONS LLC
Other - Org Name:SMILE MAKEOVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OSAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:469-781-0231
Mailing Address - Street 1:670 W CAMPBELL RD
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3393
Mailing Address - Country:US
Mailing Address - Phone:414-630-7384
Mailing Address - Fax:
Practice Address - Street 1:670 W CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3393
Practice Address - Country:US
Practice Address - Phone:414-630-7384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty