Professional Dental Alliance of Tx 43004 Pllc

NPI #1093329534 in Tyler, Texas

Provider Information

NPI Number: 1093329534
Entity Type: Organization
Organization Name: Professional Dental Alliance of Tx 43004 Pllc
Primary Specialty: Dentist - General Practice
Enumeration Date: Sep 2, 2020
Last Updated: Sep 2, 2020

Practice Location

Address: 212 OLD GRANDE BLVD STE B224
City: Tyler
State: Texas
ZIP Code: 75703-4277
Phone: (903) 509-0505

Authorized Official

Name: LAUREN HOWARD
Title: CREDENTIALING SPECIALIST
Phone: (757) 576-5479

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Dentist - General Practice — General Practice	1223G0001X	Primary

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