Provider Demographics
NPI:1750488748
Name:DENTAL AVENUE, P.A.
Entity Type:Organization
Organization Name:DENTAL AVENUE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-703-0044
Mailing Address - Street 1:300 S COTTONWOOD DR
Mailing Address - Street 2:SUITE #F
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-5751
Mailing Address - Country:US
Mailing Address - Phone:214-703-0044
Mailing Address - Fax:214-703-0691
Practice Address - Street 1:300 S COTTONWOOD DR
Practice Address - Street 2:SUITE #F
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-5751
Practice Address - Country:US
Practice Address - Phone:214-703-0044
Practice Address - Fax:214-703-0691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1702086Medicaid