Provider Demographics
NPI:1083836217
Name:HWY 30 DENTAL CLINIC P A
Entity Type:Organization
Organization Name:HWY 30 DENTAL CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AFKAMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-654-9760
Mailing Address - Street 1:1204 WOODHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112
Mailing Address - Country:US
Mailing Address - Phone:817-654-9760
Mailing Address - Fax:817-451-8389
Practice Address - Street 1:1204 WOODHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112
Practice Address - Country:US
Practice Address - Phone:817-654-9760
Practice Address - Fax:817-451-8389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX204671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty