Provider Demographics
NPI:1487398285
Name:TESLA DENTAL IMPLANT LLC
Entity type:Organization
Organization Name:TESLA DENTAL IMPLANT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:PROF
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MOM, MSC, MDS
Authorized Official - Phone:973-747-6425
Mailing Address - Street 1:5605 FM 423
Mailing Address - Street 2:SUIT 500 #410
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75036
Mailing Address - Country:US
Mailing Address - Phone:973-747-6425
Mailing Address - Fax:
Practice Address - Street 1:151 RIDGE POINT PKWY STE 400
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-8801
Practice Address - Country:US
Practice Address - Phone:817-835-6955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X2210XDental ProvidersDentistOrofacial PainGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
No292200000XLaboratoriesDental Laboratory