Provider Demographics
NPI:1437407392
Name:IDEAL DENTAL OF FORT WORTH, PLLC
Entity Type:Organization
Organization Name:IDEAL DENTAL OF FORT WORTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-337-0021
Mailing Address - Street 1:12584 N BEACH ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4249
Mailing Address - Country:US
Mailing Address - Phone:817-337-0021
Mailing Address - Fax:
Practice Address - Street 1:12584 N BEACH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-4249
Practice Address - Country:US
Practice Address - Phone:817-337-0021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty