Provider Demographics
NPI:1871238998
Name:SPARKLE123PLLC
Entity Type:Organization
Organization Name:SPARKLE123PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TANVI
Authorized Official - Middle Name:
Authorized Official - Last Name:DUSANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-853-4249
Mailing Address - Street 1:2307 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-5174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2307 4TH ST
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-5174
Practice Address - Country:US
Practice Address - Phone:281-232-2887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty