Provider Demographics
NPI:1053791061
Name:BRIDGE BREAST CENTER
Entity type:Organization
Organization Name:BRIDGE BREAST CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON-GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:214-821-3820
Mailing Address - Street 1:4000 JUNIUS ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1622
Mailing Address - Country:US
Mailing Address - Phone:214-821-3820
Mailing Address - Fax:214-821-0869
Practice Address - Street 1:4000 JUNIUS ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1622
Practice Address - Country:US
Practice Address - Phone:214-821-3820
Practice Address - Fax:214-821-0869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management