Provider Demographics
NPI:1336425651
Name:DYNASTY DENTAL
Entity type:Organization
Organization Name:DYNASTY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JANET
Authorized Official - Middle Name:DIEM
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-547-8628
Mailing Address - Street 1:717 S GREENVILLE AVE
Mailing Address - Street 2:#114
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-3317
Mailing Address - Country:US
Mailing Address - Phone:214-547-8628
Mailing Address - Fax:214-547-8675
Practice Address - Street 1:717 S GREENVILLE AVE
Practice Address - Street 2:#114
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-3317
Practice Address - Country:US
Practice Address - Phone:214-547-8628
Practice Address - Fax:214-547-8675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20556261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148653204Medicaid