Provider Demographics
NPI:1609132612
Name:GULFSIDE DENTAL
Entity Type:Organization
Organization Name:GULFSIDE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:PO BOX 734753
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2880
Mailing Address - Country:US
Mailing Address - Phone:972-869-3789
Mailing Address - Fax:972-869-3791
Practice Address - Street 1:4179 DOWLEN RD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-6852
Practice Address - Country:US
Practice Address - Phone:972-869-3789
Practice Address - Fax:972-869-3791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty