1033914965 NPI number — TAHOKA DENTISTRY PLLC

Table of content: (NPI 1033914965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033914965 NPI number — TAHOKA DENTISTRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAHOKA DENTISTRY 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:
1033914965
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1310 ESSEX LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOLFFORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79382
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-448-2346
Provider Business Mailing Address Fax Number:
806-507-3037

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2428 LOCKWOOD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAHOKA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-601-0333
Provider Business Practice Location Address Fax Number:
806-601-0339
Provider Enumeration Date:
02/14/2025

Additional Information

Authorized Official

Authorized Official Last Name:
MENLOVE
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
ROY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
801-448-2346

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)

  • Identifier: 00185523 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 440696902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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