Provider Demographics
NPI:1659913788
Name:ALTA MERE DENTAL PLLC
Entity Type:Organization
Organization Name:ALTA MERE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:RESASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-646-6004
Mailing Address - Street 1:550 ALTA MERE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76114-4053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 ALTA MERE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-4053
Practice Address - Country:US
Practice Address - Phone:480-646-6004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty