# FORNEY MIRROR LAKE DENTISTRY PLLC

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

## Provider details

- **NPI number:** 1730676735
- **Authorized official:** JUSTIN HUMPHRIES (DIRECTOR OF OPERATIONS)
- **Authorized official phone:** (972) 200-1190

## Contact information

- **Practice address:** 845 N. FM 548, SUITE 150, FORNEY, TX 75126
- **Practice address phone:** (972) 200-1190
- **Mailing address:** 845 N. FM 548, SUITE 150, FORNEY, TX 75126
- **Mailing address phone:** (972) 200-1190

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QD0000X | Dental Clinic/Center | 29699 | TX | Yes |

## Other

- **Enumeration date:** 04/16/2018
- **Last updated:** 04/16/2018