Provider Demographics
NPI:1316383482
Name:RIO GRANDE CITY DENTAL PLLC
Entity Type:Organization
Organization Name:RIO GRANDE CITY DENTAL PLLC
Other - Org Name:RODEO DENTAL AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HAILEY
Authorized Official - Last Name:DUNKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-529-8151
Mailing Address - Street 1:100 E. 15TH ST.
Mailing Address - Street 2:SUITE 520
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-6566
Mailing Address - Country:US
Mailing Address - Phone:817-529-8151
Mailing Address - Fax:817-925-1681
Practice Address - Street 1:4024 E. US HIGHWAY 83
Practice Address - Street 2:SUITE 100
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582
Practice Address - Country:US
Practice Address - Phone:817-529-8151
Practice Address - Fax:817-928-1681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-16
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168217115Medicaid
TX168217117Medicaid
TX168217118Medicaid
TX168217112Medicaid
TX168217116Medicaid
TX168217113Medicaid
TX168217114Medicaid