Provider Demographics
NPI:1821651894
Name:SPROUT DENTISTRY FOR KIDS PLLC
Entity Type:Organization
Organization Name:SPROUT DENTISTRY FOR KIDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAGE
Authorized Official - Middle Name:S
Authorized Official - Last Name:YOO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:469-301-3212
Mailing Address - Street 1:585 CHARDONNAY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75069-1542
Mailing Address - Country:US
Mailing Address - Phone:469-301-3212
Mailing Address - Fax:
Practice Address - Street 1:6675 S. CUSTER RD
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070
Practice Address - Country:US
Practice Address - Phone:469-301-3212
Practice Address - Fax:469-301-3213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-16
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2986143-06OtherMEDICAID - TMHP
TX1144508292OtherMEDICAID - DENTALQUEST
TX32386OtherMEDICAID - MCNA
TX27280OtherMEDICAID - MCNA