Provider Demographics
NPI:1194951798
Name:GRAND PRAIRIE FAMILY DENTAL GROUP
Entity type:Organization
Organization Name:GRAND PRAIRIE FAMILY DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEHROOZ
Authorized Official - Middle Name:
Authorized Official - Last Name:KHADEMAZAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-988-0900
Mailing Address - Street 1:2475 W PIONEER PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-3527
Mailing Address - Country:US
Mailing Address - Phone:972-988-0900
Mailing Address - Fax:972-660-1167
Practice Address - Street 1:2475 W PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-3527
Practice Address - Country:US
Practice Address - Phone:972-988-0900
Practice Address - Fax:972-660-1167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX155151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty