Provider Demographics
NPI:1164789509
Name:MIDKIFF ROAD PC
Entity Type:Organization
Organization Name:MIDKIFF ROAD PC
Other - Org Name:THE KID'S PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:T
Authorized Official - Middle Name:M
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-916-5031
Mailing Address - Street 1:1090 NORTHCHASE PKWY SE STE 150
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4410 N MIDKIFF RD
Practice Address - Street 2:SUITE D-1
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-4246
Practice Address - Country:US
Practice Address - Phone:432-689-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX162321223P0221X
1223E0200X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty