Provider Demographics
NPI:1013252246
Name:DENTAL PROVIDER RESOURCES 4
Entity Type:Organization
Organization Name:DENTAL PROVIDER RESOURCES 4
Other - Org Name:COMPLETE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUGGEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-328-6153
Mailing Address - Street 1:1000 TEXAN TRL
Mailing Address - Street 2:STE 229
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3776
Mailing Address - Country:US
Mailing Address - Phone:817-328-6150
Mailing Address - Fax:866-882-1702
Practice Address - Street 1:1000 TEXAN TRL
Practice Address - Street 2:STE 229
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3776
Practice Address - Country:US
Practice Address - Phone:817-328-6150
Practice Address - Fax:866-882-1702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty