Provider Demographics
NPI:1063853281
Name:RED RIVER FAMILY DENTAL, PLLC
Entity Type:Organization
Organization Name:RED RIVER FAMILY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-376-7374
Mailing Address - Street 1:1102 ASPEN RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-2947
Mailing Address - Country:US
Mailing Address - Phone:702-376-7374
Mailing Address - Fax:
Practice Address - Street 1:1320 N GRAND AVE
Practice Address - Street 2:UNIT B
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-2813
Practice Address - Country:US
Practice Address - Phone:702-376-7374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX249351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1295049781Medicaid