# PEDIATRIC DENTISTRY OF COLLEYVILLE, P.A.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1366708760
- **Authorized official:** DR. LORIA GUIATAS NAHATIS D.D.S. (OWNER / DENTIST)
- **Authorized official phone:** (817) 428-7704

## Contact information

- **Practice address:** 4109 BROWN TRL, SUITE 102, COLLEYVILLE, TX 76034-3998
- **Practice address phone:** (817) 428-7704
- **Practice address fax:** (817) 428-8919
- **Mailing address:** 4109 BROWN TRL, SUITE 102, COLLEYVILLE, TX 76034-3998
- **Mailing address phone:** (817) 428-7704
- **Mailing address fax:** (817) 428-8919

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QD0000X | Dental Clinic/Center | 21802 | TX | Yes |
| 261QD0000X | Dental Clinic/Center | — | TX | — |

## Other

- **Enumeration date:** 04/10/2012
- **Last updated:** 04/10/2012