Provider Demographics
NPI:1942515275
Name:CAMP WISDOM ROAD DENTISTRY, PA
Entity Type:Organization
Organization Name:CAMP WISDOM ROAD DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:TO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-642-2423
Mailing Address - Street 1:PO BOX 531649
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75053-1649
Mailing Address - Country:US
Mailing Address - Phone:972-642-2423
Mailing Address - Fax:972-642-2571
Practice Address - Street 1:319 W CAMP WISDOM RD
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-3332
Practice Address - Country:US
Practice Address - Phone:972-642-2423
Practice Address - Fax:972-642-2571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24103261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental