Provider Demographics
NPI:1174496137
Name:MARDESTRE
Entity type:Organization
Organization Name:MARDESTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRANIAL PROTHESIS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAFFIN BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-922-7368
Mailing Address - Street 1:11816 INWOOD RD # 1066
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-8011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2202 ROOK DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-1865
Practice Address - Country:US
Practice Address - Phone:972-922-7368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty