Provider Demographics
NPI:1962877373
Name:HOME TOWN DENTAL ALLIANCE
Entity type:Organization
Organization Name:HOME TOWN DENTAL ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MONJIT
Authorized Official - Middle Name:
Authorized Official - Last Name:GURAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-834-2600
Mailing Address - Street 1:3825 YUCCA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORTH WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111
Mailing Address - Country:US
Mailing Address - Phone:817-834-2600
Mailing Address - Fax:
Practice Address - Street 1:8901 TEHAMA
Practice Address - Street 2:SUITE 119
Practice Address - City:FORTH WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177
Practice Address - Country:US
Practice Address - Phone:817-834-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty