Provider Demographics
NPI:1730469545
Name:MODERN DENTAL PROFESSIONALS DALLAS/FT. WORTH PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS DALLAS/FT. WORTH PC
Other - Org Name:MONARCH DENTAL - GRANBURY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-212-8121
Mailing Address - Street 1:6501 WINDCREST DR
Mailing Address - Street 2:#100
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3075
Mailing Address - Country:US
Mailing Address - Phone:972-212-8119
Mailing Address - Fax:972-767-4885
Practice Address - Street 1:3902 E. US HIGHWAY 377
Practice Address - Street 2:#100
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049
Practice Address - Country:US
Practice Address - Phone:682-498-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN DENTAL PROFESSIONALS DALLAS/FT. WORTH PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty