Provider Demographics
NPI:1497015770
Name:DENTAL PROVIDER RESOURCES, PLLC
Entity type:Organization
Organization Name:DENTAL PROVIDER RESOURCES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUGGEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-328-6150
Mailing Address - Street 1:1000 TEXAN TRL
Mailing Address - Street 2:STE 229
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3776
Mailing Address - Country:US
Mailing Address - Phone:817-328-6150
Mailing Address - Fax:866-882-1702
Practice Address - Street 1:1800 BRINKER RD
Practice Address - Street 2:STE 290
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76208-6176
Practice Address - Country:US
Practice Address - Phone:940-382-1282
Practice Address - Fax:940-566-2495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty