Provider Demographics
NPI:1689808941
Name:CLINIQUE DALLAS PLASTIC SURGERY PLLC
Entity type:Organization
Organization Name:CLINIQUE DALLAS PLASTIC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ANTONETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-566-2010
Mailing Address - Street 1:7777 FOREST LN STE C212
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-6836
Mailing Address - Country:US
Mailing Address - Phone:972-566-2010
Mailing Address - Fax:855-592-2934
Practice Address - Street 1:7777 FOREST LN STE C212
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-6836
Practice Address - Country:US
Practice Address - Phone:972-566-2010
Practice Address - Fax:855-592-2934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208200000X
TX2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2931776-01Medicaid
TX2931776-01Medicaid
TX8F22313Medicare PIN