Basic Information
| Provider Information | |||||||||
| NPI: | 1215237771 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY SMILES OF ENNIS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8337 SUMMER PARK DR | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761231991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173504943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1012 E ENNIS AVE | ||||||||
| Address2: | |||||||||
| City: | ENNIS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751194345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172817947 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2010 | ||||||||
| LastUpdateDate: | 10/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | DHIR | ||||||||
| AuthorizedOfficialFirstName: | GUNJAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6172817947 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | BDS, MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 24348 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.