Provider Demographics
NPI:1740611771
Name:GREENVILLE FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:GREENVILLE FAMILY DENTISTRY PLLC
Other - Org Name:KREST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SOO
Authorized Official - Middle Name:BIN
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-354-6787
Mailing Address - Street 1:PO BOX 543248
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-3248
Mailing Address - Country:US
Mailing Address - Phone:903-454-1121
Mailing Address - Fax:903-454-2515
Practice Address - Street 1:5006 WESLEY ST.
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-6307
Practice Address - Country:US
Practice Address - Phone:903-454-1121
Practice Address - Fax:903-454-2515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty