Basic Information
| Provider Information | |||||||||
| NPI: | 1790352920 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DENTAL INNOVATION OF PLANO PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2012 SOUTHLAKE GLEN DR | ||||||||
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| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760921422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042373558 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8700 PRESTON RD STE 126 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750243321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146196329 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2021 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | YOUSUF | ||||||||
| AuthorizedOfficialFirstName: | OMAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5042373558 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.