Provider Demographics
NPI:1619380805
Name:IKIDS PEDIATRIC DENTISTRY AND ORTHODONTICS NFW
Entity Type:Organization
Organization Name:IKIDS PEDIATRIC DENTISTRY AND ORTHODONTICS NFW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUILAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-466-8554
Mailing Address - Street 1:2500 E BROAD ST STE 204
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4361
Mailing Address - Country:US
Mailing Address - Phone:817-466-8554
Mailing Address - Fax:
Practice Address - Street 1:7451 N BEACH ST
Practice Address - Street 2:STE 140
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137
Practice Address - Country:US
Practice Address - Phone:817-466-8554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX272421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty