Provider Demographics
NPI:1598041659
Name:WACO KIDS DENTAL PC
Entity Type:Organization
Organization Name:WACO KIDS DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:254-772-8330
Mailing Address - Street 1:1121 LAKE AIR DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-4417
Mailing Address - Country:US
Mailing Address - Phone:254-772-8330
Mailing Address - Fax:
Practice Address - Street 1:1121 LAKE AIR DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4417
Practice Address - Country:US
Practice Address - Phone:254-772-8330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX227641223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty