1366921231 NPI number — AC KING DENTAL PLLC

Table of content: (NPI 1366921231)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366921231 NPI number — AC KING DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AC KING 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:
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:
1366921231
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
565 W OATES RD STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75043-5462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-473-5696
Provider Business Mailing Address Fax Number:
214-602-5491

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13309 MONTFORT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75240-5116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-473-5696
Provider Business Practice Location Address Fax Number:
214-602-5491
Provider Enumeration Date:
08/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
FALLAHI
Authorized Official First Name:
SARA
Authorized Official Middle Name:
Authorized Official Title or Position:
DR
Authorized Official Telephone Number:
214-473-5696

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  31167 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 371727401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1124402300 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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