Provider Demographics
NPI:1710289061
Name:MANSFIELD FAMILY DENTISTRY
Entity Type:Organization
Organization Name:MANSFIELD FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RDH/OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:BRENTLINGER
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:817-473-0291
Mailing Address - Street 1:100 CARLIN RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3454
Mailing Address - Country:US
Mailing Address - Phone:817-473-0291
Mailing Address - Fax:682-518-1190
Practice Address - Street 1:100 CARLIN RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3454
Practice Address - Country:US
Practice Address - Phone:817-473-0291
Practice Address - Fax:682-518-1190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12539122300000X
TX24538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty