Provider Demographics
NPI:1710540232
Name:GROESBECK FAMILY DENTAL
Entity Type:Organization
Organization Name:GROESBECK FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:940-206-8956
Mailing Address - Street 1:17480 DALLAS PKWY STE 213
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-7304
Mailing Address - Country:US
Mailing Address - Phone:972-248-1221
Mailing Address - Fax:
Practice Address - Street 1:902 W YEAGUA ST
Practice Address - Street 2:
Practice Address - City:GROESBECK
Practice Address - State:TX
Practice Address - Zip Code:76642-3526
Practice Address - Country:US
Practice Address - Phone:254-729-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1902829070Medicaid