Provider Demographics
NPI:1801028071
Name:PICASSO DENTAL PLLC
Entity Type:Organization
Organization Name:PICASSO DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL FINANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-675-8753
Mailing Address - Street 1:7301 STATE HIGHWAY 161 STE 198
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2816
Mailing Address - Country:US
Mailing Address - Phone:972-869-3789
Mailing Address - Fax:
Practice Address - Street 1:1540 N HIGHWAY 77 STE 7
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-5205
Practice Address - Country:US
Practice Address - Phone:972-937-7787
Practice Address - Fax:972-937-7791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty