Provider Demographics
NPI:1255195541
Name:EA DENTAL PLLC
Entity type:Organization
Organization Name:EA DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:ABDEL MONEIM
Authorized Official - Last Name:ABBASS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-408-5631
Mailing Address - Street 1:4620 SOUTHPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-3857
Mailing Address - Country:US
Mailing Address - Phone:310-909-6839
Mailing Address - Fax:
Practice Address - Street 1:2121 NORTHWEST HWY STE 112
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-4851
Practice Address - Country:US
Practice Address - Phone:651-408-5631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-07
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1801181102Medicaid