Provider Demographics
NPI:1134637119
Name:KIDZANIA DENTAL, LLC
Entity Type:Organization
Organization Name:KIDZANIA DENTAL, LLC
Other - Org Name:KIDZANIA PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUSSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GHARRAPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-483-2445
Mailing Address - Street 1:3851 SW GREEN OAKS BLVD, ST. 123
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017
Mailing Address - Country:US
Mailing Address - Phone:817-483-2445
Mailing Address - Fax:817-483-2677
Practice Address - Street 1:26785 E. UNIVERSITY DR, ST. 102
Practice Address - Street 2:
Practice Address - City:AUBREY
Practice Address - State:TX
Practice Address - Zip Code:75068
Practice Address - Country:US
Practice Address - Phone:817-483-2445
Practice Address - Fax:817-483-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291731223P0221X
TX289101223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty