Provider Demographics
NPI:1497100978
Name:DALLAS DENTAL GROUP, PLLC
Entity type:Organization
Organization Name:DALLAS DENTAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-702-0721
Mailing Address - Street 1:2711 LBJ FWY
Mailing Address - Street 2:SUITE 122
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7315
Mailing Address - Country:US
Mailing Address - Phone:214-357-9066
Mailing Address - Fax:
Practice Address - Street 1:15123 PRESTONWOOD BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-4701
Practice Address - Country:US
Practice Address - Phone:214-357-9066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty