Provider Demographics
NPI: | 1710244546 |
---|---|
Name: | MESQUITE ENDODONTICS, PA |
Entity Type: | Organization |
Organization Name: | MESQUITE ENDODONTICS, PA |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | LORI |
Authorized Official - Middle Name: | ANNA |
Authorized Official - Last Name: | DEES |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 972-270-4456 |
Mailing Address - Street 1: | PO BOX 678074 |
Mailing Address - Street 2: | |
Mailing Address - City: | DALLAS |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75267-8074 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 972-270-4456 |
Mailing Address - Fax: | 972-270-4042 |
Practice Address - Street 1: | 1534 E INTERSTATE 30 |
Practice Address - Street 2: | SUITE 200 |
Practice Address - City: | GARLAND |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75043-4788 |
Practice Address - Country: | US |
Practice Address - Phone: | 972-270-4456 |
Practice Address - Fax: | 972-270-4042 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-04-18 |
Last Update Date: | 2012-04-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 20068 | 1223E0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223E0200X | Dental Providers | Dentist | Endodontics | Group - Single Specialty |