Provider Demographics
NPI:1376630525
Name:EAGLE MOUNTIAN FAMILY DENTAL, PC
Entity Type:Organization
Organization Name:EAGLE MOUNTIAN FAMILY DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SECRETARY TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-444-3890
Mailing Address - Street 1:116 DENVER TRL
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-3614
Mailing Address - Country:US
Mailing Address - Phone:817-444-3890
Mailing Address - Fax:
Practice Address - Street 1:116 DENVER TRL
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-3614
Practice Address - Country:US
Practice Address - Phone:817-444-3890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty