Provider Demographics
NPI:1992137707
Name:FAMILY DENTAL CLINIC, PC
Entity type:Organization
Organization Name:FAMILY DENTAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HAILEMESKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-939-8219
Mailing Address - Street 1:3128 FOREST LN
Mailing Address - Street 2:STE. 106
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7726
Mailing Address - Country:US
Mailing Address - Phone:972-241-4820
Mailing Address - Fax:972-241-1627
Practice Address - Street 1:3128 FOREST LN
Practice Address - Street 2:STE. 106
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7726
Practice Address - Country:US
Practice Address - Phone:972-241-4820
Practice Address - Fax:972-241-1627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX128918111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty