Provider Demographics
NPI:1366926297
Name:DOMINANT RESIDENCE LLC
Entity type:Organization
Organization Name:DOMINANT RESIDENCE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEMISAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-840-9157
Mailing Address - Street 1:1212 RIVERS CREEK LN
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-2907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1428 MAC ARTHUR DR STE 101
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-4437
Practice Address - Country:US
Practice Address - Phone:214-840-9157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-17
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No347C00000XTransportation ServicesPrivate Vehicle
No347D00000XTransportation ServicesTrain
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75068Medicaid