Provider Demographics
NPI:1902192289
Name:AMERISMILES DENTAL OF GRAND PRAIRE PLLC
Entity type:Organization
Organization Name:AMERISMILES DENTAL OF GRAND PRAIRE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMAN
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:NALLA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:603-233-1889
Mailing Address - Street 1:1030 N CARRIER PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-3301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1030 N CARRIER PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-3301
Practice Address - Country:US
Practice Address - Phone:603-233-1889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty