Basic Information
| Provider Information | |||||||||
| NPI: | 1427334275 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CROWN DENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8337 SUMMER PARK DR | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761231991 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 931 FM 1821 N | ||||||||
| Address2: | STE F | ||||||||
| City: | MINERAL WELLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760679131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172817947 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2011 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | DHIR | ||||||||
| AuthorizedOfficialFirstName: | GUNJAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6172817947 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 24348 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.