Provider Demographics
NPI:1518457027
Name:GILMER STREET DENTAL, PLLC
Entity type:Organization
Organization Name:GILMER STREET DENTAL, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:940-220-7833
Mailing Address - Street 1:3600 E MCKINNEY ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76209-7557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 GILMER ST
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-4193
Practice Address - Country:US
Practice Address - Phone:949-220-7833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX257351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty