Provider Demographics
NPI:1871615302
Name:HOME TOWN DENTAL OF MESQUITE PC
Entity type:Organization
Organization Name:HOME TOWN DENTAL OF MESQUITE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MONJIT
Authorized Official - Middle Name:
Authorized Official - Last Name:GURAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-528-6665
Mailing Address - Street 1:4224 GUS THOMASSON RD
Mailing Address - Street 2:4224 GUS THOMASON
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2197
Mailing Address - Country:US
Mailing Address - Phone:972-698-6685
Mailing Address - Fax:972-698-6688
Practice Address - Street 1:4224 GUS THOMASSON RD
Practice Address - Street 2:4224 GUS THOMASON
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2197
Practice Address - Country:US
Practice Address - Phone:972-698-6685
Practice Address - Fax:972-698-6688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX159871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty