Provider Demographics
NPI:1316069958
Name:PEREZ FAMILY DENTAL PA
Entity type:Organization
Organization Name:PEREZ FAMILY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AZZAH
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-922-8552
Mailing Address - Street 1:2715 W BERRY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-2346
Mailing Address - Country:US
Mailing Address - Phone:817-922-8552
Mailing Address - Fax:817-922-9286
Practice Address - Street 1:2715 W BERRY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-2346
Practice Address - Country:US
Practice Address - Phone:817-922-8552
Practice Address - Fax:817-922-9286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX197381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty