Basic Information
| Provider Information | |||||||||
| NPI: | 1528211406 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSBORO SMILES BY WIRE, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALL SMILES DENTAL & ORTHODONTICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 LBJ FREEWAY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752446158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143425757 | ||||||||
| FaxNumber: | 2143895844 | ||||||||
| Practice Location | |||||||||
| Address1: | 2480 JACKSBORO HWY | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761142201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175290994 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2008 | ||||||||
| LastUpdateDate: | 02/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | CODEL | ||||||||
| AuthorizedOfficialFirstName: | ADRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2143425757 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.