Provider Demographics
NPI:1144748153
Name:CHILDREN'S DENTAL AT PRESTON TRAIL, PC
Entity type:Organization
Organization Name:CHILDREN'S DENTAL AT PRESTON TRAIL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING AND PR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:V
Authorized Official - Last Name:DASCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-638-0303
Mailing Address - Street 1:17194 PRESTON RD STE 160
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1264
Mailing Address - Country:US
Mailing Address - Phone:214-453-2565
Mailing Address - Fax:866-407-9977
Practice Address - Street 1:17194 PRESTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1221
Practice Address - Country:US
Practice Address - Phone:615-247-7100
Practice Address - Fax:615-247-7052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-30
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN79071223P0221X
1223X0400X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty