Provider Demographics
NPI:1801040993
Name:YOON K TAK DMD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:YOON K TAK DMD A PROFESSIONAL CORPORATION
Other - Org Name:GRAND PRAIRIECHILDRENS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YOON
Authorized Official - Middle Name:K
Authorized Official - Last Name:TAK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-522-0660
Mailing Address - Street 1:5115 LAKERIDGE PARKWAY
Mailing Address - Street 2:#200
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052
Mailing Address - Country:US
Mailing Address - Phone:817-368-9170
Mailing Address - Fax:
Practice Address - Street 1:5115 LAKERIDGE PARKWAY
Practice Address - Street 2:#200
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052
Practice Address - Country:US
Practice Address - Phone:972-522-0660
Practice Address - Fax:972-522-0572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-17
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX236701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty