Provider Demographics
NPI:1811376387
Name:MEMBERS ONLY DENTAL PA
Entity Type:Organization
Organization Name:MEMBERS ONLY DENTAL PA
Other - Org Name:BELLA VITA DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOREMAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-345-6960
Mailing Address - Street 1:925 TROPHY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:TROPHY CLUB
Mailing Address - State:TX
Mailing Address - Zip Code:76262-5582
Mailing Address - Country:US
Mailing Address - Phone:817-345-6960
Mailing Address - Fax:
Practice Address - Street 1:925 TROPHY CLUB DR
Practice Address - Street 2:
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76262-5582
Practice Address - Country:US
Practice Address - Phone:817-345-6960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX239181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty