Basic Information
| Provider Information | |||||||||
| NPI: | 1104315332 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMERCE DENTAL, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY SMILES OF COMMERCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 E MCKINNEY ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762097557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9402207833 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1409 LIVE OAK ST | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754282545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9402207833 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2018 | ||||||||
| LastUpdateDate: | 05/03/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | EVERETT | ||||||||
| AuthorizedOfficialMiddleName: | CHAD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9402207833 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 23695 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.