Provider Demographics
NPI:1962092049
Name:DE GRAFFENRIED DENTAL, PLLC
Entity type:Organization
Organization Name:DE GRAFFENRIED DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RESOURCES
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-984-0614
Mailing Address - Street 1:238 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-2610
Mailing Address - Country:US
Mailing Address - Phone:903-984-0614
Mailing Address - Fax:903-984-3834
Practice Address - Street 1:238 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-2610
Practice Address - Country:US
Practice Address - Phone:903-984-0614
Practice Address - Fax:903-984-3834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1831205004OtherNPI
TX1437762622OtherNPI