Basic Information
| Provider Information | |||||||||
| NPI: | 1659967925 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BUCKNER FAMILY DENTISTRY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5800 N I 35 STE 205 | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762071438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9402207833 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1638 S BUCKNER BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752171707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9402207833 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2020 | ||||||||
| LastUpdateDate: | 12/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | EVERETT | ||||||||
| AuthorizedOfficialMiddleName: | CHAD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 9402207833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 12/21/2020 | ||||||||
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.