1356008858 NPI number — KIRKWOOD DENTAL AND ORTHODONTICS, PLLC

Table of content: (NPI 1356008858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356008858 NPI number — KIRKWOOD DENTAL AND ORTHODONTICS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIRKWOOD DENTAL AND ORTHODONTICS, 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:
1356008858
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2022
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 STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76102-6567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-529-8151
Provider Business Mailing Address Fax Number:
817-928-1681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11753 W BELLFORT ST STE 114
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAFFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77477-1327
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:
11/19/2021

Additional Information

Authorized Official

Authorized Official Last Name:
KOUYOUMDJIAN
Authorized Official First Name:
RAFFY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-529-8151

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)





Copyright © 2007-2024 www.npivalidator.com