Basic Information
| Provider Information | |||||||||
| NPI: | 1609167923 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GAURAV PURI PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY SMILES OF PALESTINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8337 SUMMER PARK DR | ||||||||
| Address2: | 8337 SUMMER PARK DRIVE | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761231991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172817941 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 419 OLD ELKHART RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | PALESTINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 758015922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172817941 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PURI | ||||||||
| AuthorizedOfficialFirstName: | GAURAV | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6172817941 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| 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.