Provider Demographics
NPI:1013608694
Name:VALLEY SQUARE DENTAL, PLLC
Entity Type:Organization
Organization Name:VALLEY SQUARE DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:945-250-0530
Mailing Address - Street 1:201 S ROGERS RD
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75060-2608
Mailing Address - Country:US
Mailing Address - Phone:951-205-5140
Mailing Address - Fax:
Practice Address - Street 1:724 W MAIN ST STE 316
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3566
Practice Address - Country:US
Practice Address - Phone:945-250-0530
Practice Address - Fax:945-250-0535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty