Provider Demographics
NPI:1730623950
Name:BRICK STREET DENTAL, PLLC
Entity type:Organization
Organization Name:BRICK STREET DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:COKER
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-592-8411
Mailing Address - Street 1:215 W RUSK ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1652
Mailing Address - Country:US
Mailing Address - Phone:903-592-8411
Mailing Address - Fax:903-592-8454
Practice Address - Street 1:215 W RUSK ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1652
Practice Address - Country:US
Practice Address - Phone:903-592-8411
Practice Address - Fax:903-592-8454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12678261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental