Provider Demographics
NPI:1023350212
Name:DENTAL PROVIDER RESOURCES 5, PLLC
Entity type:Organization
Organization Name:DENTAL PROVIDER RESOURCES 5, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
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:
Practice Address - Street 1:26219 INTERSTATE 45
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-1903
Practice Address - Country:US
Practice Address - Phone:817-328-6150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-26
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty