Provider Demographics
NPI:1609238393
Name:THE MAIN STREET DENTAL DEPOT, PLLC
Entity Type:Organization
Organization Name:THE MAIN STREET DENTAL DEPOT, PLLC
Other - Org Name:DENTAL DEPOT
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:HIMESH
Authorized Official - Middle Name:I
Authorized Official - Last Name:KANA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-795-9205
Mailing Address - Street 1:5014 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-2250
Mailing Address - Country:US
Mailing Address - Phone:469-425-9988
Mailing Address - Fax:
Practice Address - Street 1:5014 MAIN ST
Practice Address - Street 2:
Practice Address - City:THE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75056-2250
Practice Address - Country:US
Practice Address - Phone:469-425-9988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty