Basic Information
Provider Information | |||||||||
NPI: | 1972839397 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SMILE MAGIC OF DENTON, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 674330 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 75267 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8556976453 | ||||||||
FaxNumber: | 8557315147 | ||||||||
Practice Location | |||||||||
Address1: | 3600 E. MCKINNEY ST, SUITE 190 | ||||||||
Address2: |   | ||||||||
City: | DENTON | ||||||||
State: | TX | ||||||||
PostalCode: | 76209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9403872442 | ||||||||
FaxNumber: | 3403872444 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2009 | ||||||||
LastUpdateDate: | 03/09/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EVANS | ||||||||
AuthorizedOfficialFirstName: | EVERETT | ||||||||
AuthorizedOfficialMiddleName: | CHAD | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF DENTAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9408081917 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |   |
No ID Information.