Provider Demographics
NPI:1841207438
Name:DAVE, RUPAL
Entity Type:Individual
Prefix:
First Name:RUPAL
Middle Name:
Last Name:DAVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S MAIN ST STE 360
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-7004
Mailing Address - Country:US
Mailing Address - Phone:817-741-0045
Mailing Address - Fax:
Practice Address - Street 1:900 S MAIN ST STE 360
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-7024
Practice Address - Country:US
Practice Address - Phone:817-741-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX215541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies