Basic Information
| Provider Information | |||||||||
| NPI: | 1003383373 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST DALLAS DENTISTRY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17000 RED HILL AVE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926145626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458201 | ||||||||
| FaxNumber: | 3039520892 | ||||||||
| Practice Location | |||||||||
| Address1: | 6401 EAST NORTHWEST HIGHWAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143020807 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2018 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | SANTILLAN | ||||||||
| AuthorizedOfficialFirstName: | OLIVIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DDS/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2143020807 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.