Provider Demographics
NPI: | 1710530449 |
---|---|
Name: | THE DENTISTS AT GRAND PARKWAY, PLLC |
Entity Type: | Organization |
Organization Name: | THE DENTISTS AT GRAND PARKWAY, PLLC |
Other - Org Name: | THE DENTISTS AT GRAND PARKWAY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | AUTHORIZED REPRESENTATIVE |
Authorized Official - Prefix: | |
Authorized Official - First Name: | AMANDA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LIGHTFOOT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 214-702-0708 |
Mailing Address - Street 1: | 15660 DALLAS PKWY STE 925 |
Mailing Address - Street 2: | |
Mailing Address - City: | DALLAS |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75248-3323 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 214-702-0729 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1575 W GRAND PKWY S STE 1200 |
Practice Address - Street 2: | |
Practice Address - City: | KATY |
Practice Address - State: | TX |
Practice Address - Zip Code: | 77494-8313 |
Practice Address - Country: | US |
Practice Address - Phone: | 281-395-1700 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-07-22 |
Last Update Date: | 2023-05-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Multi-Specialty |