Provider Demographics
NPI:1124489646
Name:DE VINCENZO, SARA SAREMI (DMD)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:SAREMI
Last Name:DE VINCENZO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:SAREMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2728 HOOD ST APT 527
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4995
Mailing Address - Country:US
Mailing Address - Phone:248-396-0854
Mailing Address - Fax:
Practice Address - Street 1:1721 CIMARRON TRL STE 2
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3400
Practice Address - Country:US
Practice Address - Phone:817-268-1112
Practice Address - Fax:817-510-6206
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX312531223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice