Basic Information
| Provider Information | |||||||||
| NPI: | 1548590128 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GAURAV PURI PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY SMILES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 225 EXCHANGE ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760284588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174269337 | ||||||||
| FaxNumber: | 8174269336 | ||||||||
| Practice Location | |||||||||
| Address1: | 8113 CAMP BOWIE W | ||||||||
| Address2: | |||||||||
| City: | BENBROOK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761166314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172817941 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2010 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PURI | ||||||||
| AuthorizedOfficialFirstName: | GAURAV | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6172817941 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | BDS,MS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 24365 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.