Provider Demographics
NPI:1689808941
Name:CLINIQUE DALLAS PLASTIC SURGERY
Entity Type:Organization
Organization Name:CLINIQUE DALLAS PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANTONETTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-429-7557
Mailing Address - Street 1:6020 W PLANO PKWY
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-4640
Mailing Address - Country:US
Mailing Address - Phone:469-429-7557
Mailing Address - Fax:214-960-4186
Practice Address - Street 1:6020 W PLANO PKWY
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4640
Practice Address - Country:US
Practice Address - Phone:469-429-7557
Practice Address - Fax:214-960-4186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208200000X
TX2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2931776-01Medicaid
TX2931776-01Medicaid
TX8F22313Medicare PIN