Provider Demographics
NPI:1912030230
Name:MAIN DENTISTRY, P.A.
Entity Type:Organization
Organization Name:MAIN DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUJATA
Authorized Official - Middle Name:
Authorized Official - Last Name:BASAWARAJ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-370-1200
Mailing Address - Street 1:4679 STATE HIGHWAY 121
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-4010
Mailing Address - Country:US
Mailing Address - Phone:972-370-1200
Mailing Address - Fax:972-370-2679
Practice Address - Street 1:4679 STATE HIGHWAY 121
Practice Address - Street 2:SUITE 109
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75056-4010
Practice Address - Country:US
Practice Address - Phone:972-370-1200
Practice Address - Fax:972-370-2679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20290122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty