Provider Demographics
NPI:1659425759
Name:HARVARD AVENUE DENTAL CARE PA
Entity Type:Organization
Organization Name:HARVARD AVENUE DENTAL CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:PETRUTSAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-521-2258
Mailing Address - Street 1:3131 HARVARD AVENUE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205
Mailing Address - Country:US
Mailing Address - Phone:214-521-2258
Mailing Address - Fax:214-521-3425
Practice Address - Street 1:3131 HARVARD AVENUE
Practice Address - Street 2:SUITE 107
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205
Practice Address - Country:US
Practice Address - Phone:214-521-2258
Practice Address - Fax:214-521-3425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX187741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty