Provider Demographics
NPI:1386962660
Name:GREAT SOUTHWEST FAMILY DENTAL
Entity type:Organization
Organization Name:GREAT SOUTHWEST FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:H
Authorized Official - Last Name:TRUONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-660-8457
Mailing Address - Street 1:2501 W I 20
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-3947
Mailing Address - Country:US
Mailing Address - Phone:972-660-8457
Mailing Address - Fax:
Practice Address - Street 1:2501 W I 20
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3947
Practice Address - Country:US
Practice Address - Phone:972-660-8457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2203941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty