Provider Demographics
NPI:1770929887
Name:DENTAL DISTINCTION, PLLC
Entity type:Organization
Organization Name:DENTAL DISTINCTION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:469-230-7338
Mailing Address - Street 1:609 W 15TH STREET
Mailing Address - Street 2:SUITE# 130
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075
Mailing Address - Country:US
Mailing Address - Phone:972-423-3322
Mailing Address - Fax:
Practice Address - Street 1:609 W 15TH ST
Practice Address - Street 2:SUITE# 130
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-8876
Practice Address - Country:US
Practice Address - Phone:972-423-3322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223P0106X, 1223X0400X
TX24193122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty