Provider Demographics
NPI:1902105711
Name:RADIANCE DENTISTRY
Entity Type:Organization
Organization Name:RADIANCE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MOUNIR
Authorized Official - Middle Name:
Authorized Official - Last Name:ISKANDAR
Authorized Official - Suffix:
Authorized Official - Credentials:BDS,MSD
Authorized Official - Phone:972-258-1702
Mailing Address - Street 1:1235 KINWEST PKWY
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-3403
Mailing Address - Country:US
Mailing Address - Phone:972-258-1702
Mailing Address - Fax:972-258-1703
Practice Address - Street 1:1235 KINWEST PKWY
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3403
Practice Address - Country:US
Practice Address - Phone:972-258-1702
Practice Address - Fax:972-258-1703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-18
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX239211223G0001X
1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX27805703Medicaid