Provider Demographics
NPI:1285994483
Name:JSN DENTAL PLLC
Entity type:Organization
Organization Name:JSN DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUGUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-381-1122
Mailing Address - Street 1:10611 FAULKNER PT
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-5429
Mailing Address - Country:US
Mailing Address - Phone:858-231-0299
Mailing Address - Fax:
Practice Address - Street 1:8849 N TARRANT PKWY
Practice Address - Street 2:SUITE# 105
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76182-7695
Practice Address - Country:US
Practice Address - Phone:817-381-1122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX234601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty