Provider Demographics
NPI: | 1700296787 |
---|---|
Name: | JEWEL DENTAL GROUP, PLLC |
Entity Type: | Organization |
Organization Name: | JEWEL DENTAL GROUP, PLLC |
Other - Org Name: | DENTAL IMPRESSIONS |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | SWEETA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | WALIA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 214-862-3100 |
Mailing Address - Street 1: | 3401 WOLFE CIR |
Mailing Address - Street 2: | |
Mailing Address - City: | PLANO |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75025-2227 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 910 N GALLOWAY AVE |
Practice Address - Street 2: | SUITE 202 |
Practice Address - City: | MESQUITE |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75149-2409 |
Practice Address - Country: | US |
Practice Address - Phone: | 682-472-8473 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-04-30 |
Last Update Date: | 2014-04-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 22451 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |