Basic Information
| Provider Information | |||||||||
| NPI: | 1609332733 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH TEXAS BOULEVARD DENTAL, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 E MCKINNEY ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762097557 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 802 N TEXAS BLVD | ||||||||
| Address2: | |||||||||
| City: | WESLACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785964808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9402207833 | ||||||||
| FaxNumber: | 8557315147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2019 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | COPELAND | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
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| AuthorizedOfficialTitleorPosition: | DENTIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9402207833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.