Provider Demographics
NPI:1245772995
Name:4K DENTISTRY PLLC
Entity Type:Organization
Organization Name:4K DENTISTRY PLLC
Other - Org Name:4K DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:OLULAJA OLAYIWOLA
Authorized Official - Last Name:KOFOWOROLA-KUTI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD; MPH; BDS; CCRC
Authorized Official - Phone:336-354-9314
Mailing Address - Street 1:21434 PROVINCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-7587
Mailing Address - Country:US
Mailing Address - Phone:281-398-4369
Mailing Address - Fax:281-398-4328
Practice Address - Street 1:21434 PROVINCIAL BLVD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-7587
Practice Address - Country:US
Practice Address - Phone:281-398-4369
Practice Address - Fax:281-398-4328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-11
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32432261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental