Provider Demographics
NPI:1124242425
Name:FORMAGUS, NACE ANTHONY JR
Entity type:Individual
Prefix:DR
First Name:NACE
Middle Name:ANTHONY
Last Name:FORMAGUS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8080 N CENTRAL EXPY
Mailing Address - Street 2:380
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-1838
Mailing Address - Country:US
Mailing Address - Phone:214-340-9179
Mailing Address - Fax:
Practice Address - Street 1:8080 N CENTRAL EXPY
Practice Address - Street 2:380
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-1838
Practice Address - Country:US
Practice Address - Phone:214-340-9179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12.4351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice