Provider Demographics
NPI:1629253893
Name:KB DENTAL II P.C.
Entity Type:Organization
Organization Name:KB DENTAL II P.C.
Other - Org Name:SOUTHFORK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BINDU
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOLLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-459-7500
Mailing Address - Street 1:1071 W FM 3040
Mailing Address - Street 2:STE800
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-7904
Mailing Address - Country:US
Mailing Address - Phone:972-459-7500
Mailing Address - Fax:972-459-7555
Practice Address - Street 1:1071 W FM 3040
Practice Address - Street 2:STE800
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-7904
Practice Address - Country:US
Practice Address - Phone:972-459-7500
Practice Address - Fax:972-459-7555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty