Provider Demographics
NPI:1639893027
Name:DALLAS FORT WORTH ENDODONTICS, PLLC
Entity Type:Organization
Organization Name:DALLAS FORT WORTH ENDODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, ENDODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:COUNTRYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-340-7943
Mailing Address - Street 1:14965 OAK ST
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-1576
Mailing Address - Country:US
Mailing Address - Phone:903-340-7943
Mailing Address - Fax:
Practice Address - Street 1:1750 CAVENDER DR
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3546
Practice Address - Country:US
Practice Address - Phone:817-786-4696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty