Provider Demographics
NPI:1750604609
Name:MAPLE FAMILY DENTAL PLLC
Entity type:Organization
Organization Name:MAPLE FAMILY DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DDS, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITA
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-517-9608
Mailing Address - Street 1:4611 COLUMBIA AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75226-2306
Mailing Address - Country:US
Mailing Address - Phone:214-517-9608
Mailing Address - Fax:214-827-8001
Practice Address - Street 1:4611 COLUMBIA AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75226-2306
Practice Address - Country:US
Practice Address - Phone:214-517-9608
Practice Address - Fax:214-827-8001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-07
Last Update Date:2010-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223X0400X
TX21968122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty