Provider Demographics
NPI:1992096952
Name:IDEAL DENTAL OF FLOWER MOUND, PC
Entity type:Organization
Organization Name:IDEAL DENTAL OF FLOWER MOUND, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:CANTU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-361-0600
Mailing Address - Street 1:2616 LONG PRAIRIE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-4839
Mailing Address - Country:US
Mailing Address - Phone:972-899-3499
Mailing Address - Fax:972-899-3498
Practice Address - Street 1:2616 LONG PRAIRIE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-4839
Practice Address - Country:US
Practice Address - Phone:972-899-3499
Practice Address - Fax:972-899-3498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty