Provider Demographics
NPI:1912252750
Name:CLEAN DENTAL OF DALLAS, P.C.
Entity Type:Organization
Organization Name:CLEAN DENTAL OF DALLAS, P.C.
Other - Org Name:CLEAN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SANG
Authorized Official - Middle Name:W
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-765-6213
Mailing Address - Street 1:4402 GUS THOMASSON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2232
Mailing Address - Country:US
Mailing Address - Phone:214-765-6212
Mailing Address - Fax:
Practice Address - Street 1:4907 SPRING AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75210-1360
Practice Address - Country:US
Practice Address - Phone:214-765-6212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX236531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty