Provider Demographics
NPI:1871909127
Name:PECAN TREE DENTAL
Entity type:Organization
Organization Name:PECAN TREE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:QUINN
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-371-2007
Mailing Address - Street 1:2672 BASSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-4700
Mailing Address - Country:US
Mailing Address - Phone:602-300-1059
Mailing Address - Fax:
Practice Address - Street 1:775 W WESTCHESTER PKWY STE 101
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-2851
Practice Address - Country:US
Practice Address - Phone:972-262-5111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30205305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization