1316383482 NPI number — RIO GRANDE CITY DENTAL PLLC

Table of content: (NPI 1316383482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316383482 NPI number — RIO GRANDE CITY DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIO GRANDE CITY DENTAL PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RODEO DENTAL AND ORTHODONTICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316383482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E. 15TH ST.
Provider Second Line Business Mailing Address:
SUITE 520
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76102-6566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-529-8151
Provider Business Mailing Address Fax Number:
817-925-1681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4024 E. US HIGHWAY 83
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
RIO GRANDE CITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78582
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-529-8151
Provider Business Practice Location Address Fax Number:
817-928-1681
Provider Enumeration Date:
05/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DUNKLIN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
HAILEY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-529-8151

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 168217115 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 168217117 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 168217118 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 168217112 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 168217116 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 168217113 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 168217114 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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