Provider Demographics
NPI:1649972035
Name:SUNNY SIDE OF THE STREET PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:SUNNY SIDE OF THE STREET PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYFFANI
Authorized Official - Middle Name:TYNNEIL
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-799-8778
Mailing Address - Street 1:5801 GOLDEN TRIANGLE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4411
Mailing Address - Country:US
Mailing Address - Phone:817-799-8778
Mailing Address - Fax:817-799-6671
Practice Address - Street 1:5725 GOLDEN TRIANGLE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-4473
Practice Address - Country:US
Practice Address - Phone:817-799-8778
Practice Address - Fax:817-799-6671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-20
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty