Provider Demographics
NPI:1225282320
Name:KTV DENTAL , PA
Entity Type:Organization
Organization Name:KTV DENTAL , PA
Other - Org Name:COWTOWN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:THI
Authorized Official - Last Name:VAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-591-0298
Mailing Address - Street 1:2530 SARA JANE PKWY APT 333
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8604
Mailing Address - Country:US
Mailing Address - Phone:954-591-0298
Mailing Address - Fax:
Practice Address - Street 1:2717 8TH AVE.
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110
Practice Address - Country:US
Practice Address - Phone:954-591-0298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX231331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty