Provider Demographics
NPI:1164178026
Name:MENLOVE DENTAL, PLLC
Entity Type:Organization
Organization Name:MENLOVE DENTAL, PLLC
Other - Org Name:FAMILY CAMP DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:MENLOVE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:806-507-7777
Mailing Address - Street 1:4202 AVE Q
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79412-3387
Mailing Address - Country:US
Mailing Address - Phone:806-507-7777
Mailing Address - Fax:806-507-3037
Practice Address - Street 1:4202 AVENUE Q
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79412-1708
Practice Address - Country:US
Practice Address - Phone:806-507-7777
Practice Address - Fax:806-507-3037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-01
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
No125Q00000XDental ProvidersOral MedicinistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX38058OtherDENTAL LICENSE