Provider Demographics
NPI:1679846083
Name:GLEAM DENTAL LLC
Entity Type:Organization
Organization Name:GLEAM DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:FIELD
Authorized Official - Middle Name:G
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-573-6100
Mailing Address - Street 1:3636 N. MACAURTHUR
Mailing Address - Street 2:STE. 140
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062
Mailing Address - Country:US
Mailing Address - Phone:972-573-6100
Mailing Address - Fax:972-573-6105
Practice Address - Street 1:3636 N. MACAURTHUR
Practice Address - Street 2:STE 140
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062
Practice Address - Country:US
Practice Address - Phone:972-573-6100
Practice Address - Fax:972-573-6105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GLEAM DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23874122300000X
122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTPI205977609Medicaid