1437407392 NPI number — IDEAL DENTAL OF FORT WORTH, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437407392 NPI number — IDEAL DENTAL OF FORT WORTH, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDEAL DENTAL OF FORT WORTH, 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:
Provider Other Organization Name Type Code:
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:
1437407392
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12584 N BEACH ST
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76244-4249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-337-0021
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12584 N BEACH ST
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76244-4249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-337-0021
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ALLES
Authorized Official First Name:
RODNEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-337-0021

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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