Provider Demographics
NPI:1679865836
Name:LEGACY DENTISTRY
Entity Type:Organization
Organization Name:LEGACY DENTISTRY
Other - Org Name:LEGACY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TONI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ENGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-723-1148
Mailing Address - Street 1:151 WALTON WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-8009
Mailing Address - Country:US
Mailing Address - Phone:972-723-1148
Mailing Address - Fax:972-723-1035
Practice Address - Street 1:151 WALTON WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-8009
Practice Address - Country:US
Practice Address - Phone:972-723-1148
Practice Address - Fax:972-723-1035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX239521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty