Provider Demographics
NPI:1609167923
Name:GAURAV PURI PA
Entity Type:Organization
Organization Name:GAURAV PURI PA
Other - Org Name:FAMILY SMILES OF PALESTINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GAURAV
Authorized Official - Middle Name:
Authorized Official - Last Name:PURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-281-7941
Mailing Address - Street 1:8337 SUMMER PARK DR
Mailing Address - Street 2:8337 SUMMER PARK DRIVE
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-1991
Mailing Address - Country:US
Mailing Address - Phone:617-281-7941
Mailing Address - Fax:
Practice Address - Street 1:419 OLD ELKHART RD
Practice Address - Street 2:STE 110
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-5922
Practice Address - Country:US
Practice Address - Phone:617-281-7941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX243651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty