Provider Demographics
NPI:1053719666
Name:PARK PLACE PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:PARK PLACE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-465-1888
Mailing Address - Street 1:3602 MATLOCK RD
Mailing Address - Street 2:STE 208
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-3616
Mailing Address - Country:US
Mailing Address - Phone:817-465-1888
Mailing Address - Fax:817-466-8879
Practice Address - Street 1:3602 MATLOCK RD
Practice Address - Street 2:STE 208
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-3616
Practice Address - Country:US
Practice Address - Phone:817-465-1888
Practice Address - Fax:817-466-8879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29889122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty