Provider Demographics
NPI:1730924259
Name:MYRIAD DENTAL STUDIO PLLC
Entity type:Organization
Organization Name:MYRIAD DENTAL STUDIO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:940-226-2000
Mailing Address - Street 1:3000 FM 407 E STE 300
Mailing Address - Street 2:
Mailing Address - City:BARTONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76226-9366
Mailing Address - Country:US
Mailing Address - Phone:719-466-3467
Mailing Address - Fax:
Practice Address - Street 1:3000 FM 407 E STE 300
Practice Address - Street 2:
Practice Address - City:BARTONVILLE
Practice Address - State:TX
Practice Address - Zip Code:76226-9366
Practice Address - Country:US
Practice Address - Phone:719-466-3467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-26
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental