Provider Demographics
NPI:1750028452
Name:PRUITT, CHANDLER AMY LYNNE (DDS)
Entity Type:Individual
Prefix:
First Name:CHANDLER
Middle Name:AMY LYNNE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 MCFARLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-1627
Mailing Address - Country:US
Mailing Address - Phone:214-729-9119
Mailing Address - Fax:
Practice Address - Street 1:100 KINGS FORT PKWY STE 100
Practice Address - Street 2:
Practice Address - City:KAUFMAN
Practice Address - State:TX
Practice Address - Zip Code:75142-3544
Practice Address - Country:US
Practice Address - Phone:469-414-0670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX392611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program