Provider Demographics
NPI:1588259840
Name:BRECKENRIDGE DENTAL PLLC
Entity type:Organization
Organization Name:BRECKENRIDGE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KAMALPREET
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALLU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:347-759-2152
Mailing Address - Street 1:111 S MILLER ST
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:76424-4355
Mailing Address - Country:US
Mailing Address - Phone:254-559-2420
Mailing Address - Fax:
Practice Address - Street 1:111 S MILLER ST
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:TX
Practice Address - Zip Code:76424-4355
Practice Address - Country:US
Practice Address - Phone:254-559-2420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental