Provider Demographics
NPI:1760134480
Name:SISOMBATH DENTAL PC
Entity Type:Organization
Organization Name:SISOMBATH DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:SISOMBATH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:469-296-8714
Mailing Address - Street 1:5331 E MOCKINGBIRD LN APT 617
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-0911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 S PRESTON RD STE 60
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-2780
Practice Address - Country:US
Practice Address - Phone:469-296-8714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental